COLUMBIA  LIBRARIES  OFFSITt 

HEALTH  SCIENCES  STANDARD 


HX00040118 


College  ot  p|)psiician£f  anb  ^urgeonss 


3Br.  CtittJin  p.  Cragin 

1859-1918 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofsciencOOgarr 


A  TEXT-BOOK 


OF 


THE   SCIENCE  AND   ART 


OF 


OBSTETRICS 


BY 

HENRY  J.   GARRIGUES,  A.M.,  M.D. 

CONSULTING  OBSTETRIC    SURGEON   TO    THE    NEW  "YORK    MATERNITY   HOSPITAL  ;    GYNECOLOGIST 

TO    ST.    mark's  HOSPITAL  ;    PROFESSOR  OF  OBSTETRICS  IN  THE  POST-GRADUATE    MEDICAL 

SCHOOL  (retired)  ;    PROFESSOR  OF   GYNAECOLOGY  AND    OBSTETRICS   IN  THE  SCHOOL 

FOR   CLINICAL    MEDICINE  (rETIREd)  ;    HONORARY  FELLOW    OF    THE    AMERICAN 

GYNECOLOGICAL    SOCIETY  ;      HONORARY     FELLOW    OF    THE    OBSTETRICAL 

SOCIETY   OF    EDINBURGH  ;    EX-PRESIDENT   OF    THE  GERMAN    MEDICAL 

SOCIETY,   ETC. 


WITH  FIVE  HUNDRED  AND  FOUR  ILLUSTRATIONS 


PHILADELPHIA   AND   LONDON 
J.   B.    LIPPINCOTT    COMPANY 

1902 


Copyright,  1902, 

BY 

J.  B.  LippiNcoTT  Company. 


ELECTROTYPED    AND    PRINTED    BY   J.   B.   LIPPINCOTT    COMPANY,    PHILADELPHIA,    U.S.A. 


PREFACE 


Unlike  gynaecology,  the  science  and  art  of  obstetrics  are  hundreds 
and  even  thousands  of  years  old,  and  most  of  its  principles  have 
long  been  firmly  established.  During  the  last  twenty-five  years  only 
four  really  great  improvements  have  been  made, — antisepsis,  with  its 
offspring  asepsis,  the  axis-traction  forceps,  the  improved  Caesarean 
section,  and  the  revival  of  symphyseotomy.  This  science  can,  there- 
fore, be  taught  in  a  more  didactic  and  less  discursive  way. 

The  aim  of  the  author  has  been  strictly  to  write  a  text-book,  not  a 
book  of  reference,  as  many  books  are  that  are  called  text-books,  but 
abound  in  details,  which  only  show  the  reading  of  their  authors,  and 
embarrass  the  student  who  wants  to  become  acquainted  with  this 
branch  of  medicochirurgical  science  as  well  as  the  practitioner  who 
seeks  information  about  a  case  under  his  care.  Few  proper  names 
have  been  introduced,  and  these  mostly  where  it  was  necessary  to 
designate  certain  instruments  or  methods  of  operating.  The  refer- 
ences made  to  the  author's  former  writings  should  chiefly  be  looked 
upon  as  vouchers  for  his  right  to  take  the  magisterial  tone  used  in 
the  text,  as  they  show  that  the  book  largely  is  based  on  personal 
observation  and  research.  Still,  in  treating  of  subjects  about  which 
he  has  written  before,  everything  has  been  brought  up  to  date. 

Beginners  ought  to  study  bbstetrics  before  gynaecology,  since  the 
former  is  the  key  to  the  latter.  But,  on  the  other  hand,  it  would 
lead  too  far  to  describe  in  the  text  all  that  should  be  known  by 
the  student  in  order  to  understand  obstetrics ;  and  it  Avould  be  too 
difficult  for  him  to  find  what  he  needs  in  a  text-book  of  gynaecology. 
The  author,  therefore,  frequently  refers  to  pages  in  his  "  Text-book 
of  Diseases  of  Women,"  so  as  to  enable  the  reader  readily  to  look 
up  those  points  which  he  needs  for  his  obstetric  studies. 

In  presenting  the  science  and  art  of  obstetrics  the  author  lias 
striven  to  lead  the  reader  gradually  from  the  simple  to  the  compli- 


IV 


PREFACE. 


cated,  from  the  easy  to  the  difficult.  All  matters  referring  to  the 
normal  process  of  pregnancy,  labor,  and  puerpery  have,  therefore, 
been  placed  before  the  description  of  abnormal  conditions  and  their 
treatment. 

Symphyseotomy  being  practically  a  new  operation,  and  the  Cesa- 
rean section  having  undergone  so  great  changes  in  recent  times,  the 
author  has  not  thought  it  proper  to  treat  of  these  operations  in  the 
same  didactic  tone  in  which  the  bulk  of  the  book  is  written,  but  has 
entered  into  a  discussion  of  different  views  and  given  references  to 
many  publications  concerning  them. 

It  is  a  peculiarity  of  obstetric  art  that  the  physician  from  the 
very  moment  he  begins  practising  may  encounter  any  kind  of  com- 
plications and  difficulties,  which  have  to  be  met  at  once.  The  author 
has,  therefore,  endeavored  to  be  as  brief,  clear,  and  precise  in  expres- 
sion as  possible,  although,  on  the  other  hand,  he  has  tried  to  avoid 
unnecessary  scientific  dryness. 

The  work  is  so  profusely  illustrated  that  one  who  is  somewhat 
familiar  with  this  branch  of  science  can  refresh  his  memory  by 
merely  turning  over  its  pages  and  looking  at  the  pictures.  Many 
of  the  illustrations  are  new  and  drawn  directly  from  nature,  in  order 
to  avoid  the  manifold  inaccuracies  found  in  current  representations 
even  of  such  solid  objects  as  the  bones  of  the  pelvis. 

As  far  as  possible,  objects  are  represented  in  their  actual  size, 
which  is  deemed  much  more  instructive  than  to  ask  the  reader  to 
draw  on  his  imagination  in  understanding  mechanical  problems  and 
questions  of  development. 


CONTENTS 

NORMAL   DIVISION 

PART    I.— FOUNDATION. 

CHAPTER   I. 
Puberty 1 

CHAPTER   II. 
Nubility 2 

CHAPTER   III. 
Ovulation  and  the  Ovum 2 

CHAPTER   IV. 
Menstruation 13 

CHAPTER  V. 
Copulation 18 

CHAPTER   VI. 
Fecundation 21 

PART    II.— NORMAL    PREGNANCY. 

CHAPTER  I. 
Transportation  and  Embedding  of  the  Ovum.     Decidua 27 

CHAPTER  II. 
Chorion 31 

CHAPTER   III. 
Placenta 34 

CHAPTER  IV. 
Development  of  the  Ovum  and  the  Embryo 36 

CHAPTER  V. 
Amnion   40 

CHAPTER  VI. 
Allantois 40 

v 


vi  CONTENTS. 

CHAPTER  VII. 


PAGE 

Yolk-Sac,  or  Umbilical  Vesicle 41 

CHAPTER  A^III. 

FORilATIOX    OF    THE    UMBILICAL    CoRD 42 

CHAPTER   IX. 
JSTUTRITION 43 

CHAPTER   X. 
Secretion  and  Excretion 45 

CHAPTER  XL 
Respiration - 46 

CHAPTER  XII. 
Circulation 46 

CHAPTER  XIII. 
Other  Functions 51 

CHAPTER   XIV. 
Duration  op  Pregnancy 51 

CHAPTER  XV. 
Development  of  the  Fcetus  in  each  Lunar  Month  ....    54 

CHAPTER   XVI. 
Viability . 63 

CHAPTER  XVII. 
Maturity  of  the  Foetus 64 

CHAPTER   XVIII. 
Ovum  and  Placenta  at  Term 66 

CHAPTER  XIX. 
Cause  of  the  Sex  of  the  Fcetus    73 

CHAPTER  XX. 

Attitude,  Presentation,  and  Position  of  the  Fcetus   75 

CHAPTER   XXL 
Changes  in  the  Mother  during  Prec^nancy    84 

CHAPTER  XXII. 
The  Uterus  at  the  End  of  Pregnancy 98 

CHAPTER  XXIII. 
Signs  of  Pregnancy 100 


CONTENTS.  Yii 

CHAPTER  XXIV.  ^^^^ 

Differential  Diagnosis  of  Pregnancy 105 

CHAPTER   XXV. 
Physical  Examination 107 

CHAPTER  XXVI. 

Diagnosis  between  the  First  and  Later  Pregnancies 121 

CHAPTER  XXVII. 
Bacteriology  of  the  Vagina 125 

CHAPTER  XXVIII. 
Dress  and  Regimen  during  Pregnancy 126 


PART    III.— NORMAL    LABOR. 

CHAPTER  I. 
Causes  of  Labor 129 

CHAPTER  11. 
The  Anatojiy  of  the  Parturient  Canal 130 

A.  The  Pelvis 130 

g  1.  The  Bones  of  the  Pelvis 130 

I  2.  The  Ligaments  of  the  Pelvis 135 

I  3.  The  Pelvis  as  a  Whole 137 

§  4.  The  Inclination  and  Axes  of  the  Pelvis 141 

I  5.  Differences  between  the  Male  and  the  Female  Pelvis 144 

I  6.  The  Pelvis  of  the  New-Born 144 

I  7.  Differences  of  the  Pelvis  in  Different  Races 146 

B.  The  Soft  Parts  of  the  Parturient  Canal 147 

§  1.  Muscles 147 

^  2.  Fasciae  of  the  Perineum 151 

§  3.  The  Uterus.     The  Lower  Uterine  Segment 153 

^  4.  The  Cervix,  the  Vagina,  and  the  Vulva 155 

CHAPTER   HI. 
The  Fetal  Head 156 

CHAPTER  IV. 
Chief  Features  of  Childbirth 161 

CHAPTER  V. 

The  Expellant  Forces 163 

I  1.  Innervation  of  the  Uterus 163 

^  2.  Labor-Pains 163 

i  3.  Stages  of  Labor 167 

^  4.  Influence  of  Labor  on  the  Mother 177 

I  5.  Influence  of  Labor  on  the  Child 178 

§  6.  Duration  of  Labor 179 


viii  CONTENTS. 

CHAPTER  VI.  P^OE 

Cause  of  Respiration 179 

CHAPTER  VII. 
Conduct  of  Normal  Labor 180 

CHAPTER  VIII. 
Care  of  the  New-Born  Child 208 

CHAPTER  IX. 
Midwives 211 

CHAPTER  X. 
Lying-in  Institutions 216 

PART    IV.— NORMAL    PUERPERY. 
Definition 225 

CHAPTER   I. 
The  Condition  op  the  Mother 226 

CHAPTER   II. 
The  Care  op  the  Mother 233 

CHAPTER   III. 
Signs  op  the  Puerperal  State •  •  243 

CHAPTER  IV. 
The  Condition  op  the  Child 244 

CHAPTER  V. 
The  Care  of  the  Child ■  246 

CHAPTER  VI. 
Congenital  Weakness • 253 


ABNORMAL   DIVISION 

PART    L— ABNORMAL    PREGNANCY. 

CHAPTER  I. 

Multiple  Fetation 257 

§  1.  Superfecundation 257 

?  2.  Superfetation 257 

g  3.  Common  Multiple  Fetation 258 


CONTENTS.  ix 

CHAPTER  II.  p^g^ 

The  Death  of  the  Fcetus ; 261 

CHAPTER   HI. 

Inteeeuption  of  Pregnancy 262 

§  1,  Abortion 262 

I  2.  Habitual  Abortion 268 

I  3.  Artificial  Abortion 269 

§  4.  Criminal  Abortion 270 

I  5.  Premature  Labor 271 

^  6.  Induction  of  Premature  Labor 272 

g  7.  Hunger  Cure 274 

CHAPTER  1\. 
Missed  Labor 275 

CHAPTER  Y. 
Missed  Abortion 276 

CHAPTER  YI. 
Diseases  of  the  Genital  Organs 276 

'i  1.  Malformations 276 

Uterus  Duplex  Separatus,  or  LTterus  Didelphys 278 

Uterus  Unicornis 279 

Uterus  Bicornis 281 

Uterus  Septus,  or  L^'terus  Bilocularis 282 

^  2.  Inflammations 282 

Decidual  Endometritis 282 

Metritis 284 

Perimetritis 284 

Colpitis,  Yaginitis,  or  Elytritis 284 

JEdoeitis,  or  Yulvitis 287 

§  3.  Pruritus  Yulvse 288 

g  4.  Tumors    289 

Yegetations,  Yenereal  Warts,  or  Condylomata  Acuminata. .  289 

Yaricose  Yeins 291 

Haematoma,  or  Tbrombus 292 

Myoma  of  the  Uterus 292 

Sarcoma  and  Carcinoma  of  the  Uterus 293 

Ovarian  Cyst 295 

Operations  during  Pregnancy 296 

^  5.  Displacements 297 

Anteflexion  of  the  Uterus 297 

Anteversion  of  the  Uterus 297 

Retroflexion  of  the  Uterus 297 

Retroversion  of  the  L'terus 300 

Prolapse  and  Procidentia  of  the  Uterus 300 

Oi^dema  of  the  Cervix 301 

Hernia  Uteri,  or  Hysterocele 301 

Ectoxjic  Gestation 302 


X  CONTENTS. 

CHAPTER  VII. 

PAGE 

Systemic  Distukbances  due  to  Peegnancy 318 

^  1.  Hyperemesis,  Severe  or  Uncontrollable  Vomiting 318 

I  2.  Ptyaiism 321 

?  3.  Constipation  or  Diarrhoea 321 

^  4.  Toothache  and  Caries  of  the  Teeth 321 

§  5.  Cough 321 

§  6.  Dyspnoea 321 

i  7.  Palpitations '. 321 

§  8.  Lypothymia 322 

f  9.  Insomnia 322 

§  10.  Headache 322 

§  11.  Neuralgia 322 

§  12.  Chorea 323 

^  13.  Tetany 323 

i  14.  Tetanus 324 

I  15.  Paralysis 324 

I  16.  Convulsions 325 

§  17.  Insanity 333 

§  18.  Irritability  of  the  Bladder 334 

§  19.  Enuresis 334 

§  20.  Retention  of  Urine 334 

§  21.  The  Kidney  of  Pregnancy  and  Nephritis 334 

§  22.  Fever  of  Pregnancy 335 

1  23.  Icterus 335 

§  24.  Progressive  Pernicious  Angemia 336 

§  25.  Leucocythaemia,  or  Leukaemia 336 

§  26.  Pemphigus 337 

§  27.  Impetigo  Herpetiformis 337 

i  28.  Mastitis •• 337 

2  29.  Eczema  of  the  Areola 337 


CHAPTER  VIII. 

Complication  with  Acute  Infectious  Diseases 338 

'i  1 .  Gonorrhoea 338 

I  2.  Other  Acute  Infectious  Diseases  :  Scarlet  Fever,  Measles,  Small- 
pox, Malaria,  Influenza,  Typhoid  Fever,  Cholera,  Pneumonia, 
Pleurisy,  Erysipelas,  Hydrophobia,  Septicaemia 338 


CHAPTER  IX. 

Complication  with  Chronic  Diseases 340 

§  1.  Syphilis ■ 340 

1  2.  Tuberculosis 342 

§  3.  Heart  Disease 343 

^  4.  Haemophilia - 344 

2  5.  Hernia 344 


CHAPTER  X. 

Death  of  the  INIother  during  Pregnancy 345 


CONTENTS.  xi 

CHAPTER  XI. 

PAGE 

Diseases  of  the  Ovum 346 

I  1.  Amniotic  Bands 346 

I  2.  Hydramnion,  or  Hydramnios 346 

^  3.  Scanty  Liquor  Amnii 349 

?  4.  Cystic  Degeneration  of  the  Villi  of  the  Chorion  ;   Vesicular 

Mole 349 

I  5.  Cellular  Hypertrophy  and  Hyperplasia  of  the  Villi,  or  Myxoma 

Fibrosum  Placentae 352 

§  6.  Diseases  of  the  Decidua 352 

Atrophy  of  Decidua 352 

Hypertrophy  of  Decidua 352 

Cystic  Decidua 352 

Hemorrhagic  Endometritis  ;  Fleshy  Mole 352 

Hydrorrhoea  Gravidarum    352 

?  7.  Anomalies  of  the  Placenta 354 

?  8.  Anomalies  of  the  Umbilical  Cord 355 

I  9.  Changes  in  the  Foetus  after  its  Death 355 


PART    II.— ABNORMAL    LABOR    (DYSTOCIA). 

CHAPTER  I. 
Faulty  Uterine  Contractions 357 

CHAPTER   II. 
Faulty  Abdominal  Pressure 361 

CHAPTER  III. 

Unfavorable  Position,  Presentation,  or  Attitude  of  Fcetus 362 

§  1.  Occipitoposterior  Positions 362 

§  2.  Occipitolateral  Position 365 

^  3.  Lateral  Obliquity  of  the  Head 366 

^  4.  Face  Presentation 367 

§  5.  Brow  Presentation 374 

§  6.  Pelvic  Presentation 376 

§  7.  Transverse  Presentations 391 

?  8.  Compound  Presentation 395 

CHAPTER  IV. 

Excessive  Size  of  Fcetus 397 

?  1.  Giant  Children 397 

§  2.  Hydrocephalus 399 

§  3.  Other  Cephalic  Enlargements 401 

§  4.  Abdominal  Enlargement 401 

§  5.  Other  Swellings 402 

CHAPTER  V. 
Twin  Labor 403 


xii  CONTENTS. 

CHAPTER  VI.  p^eE 

Double  Monstrosities • 408 

CHAPTER  VII. 

Abnormalities  of  the  Ovr ji 412 

I  1.  Abnormal  Membranes 412 

?  2.  Abnormalities  of  the  Umbilical  Cord 413 

§  3.  Retained  and  Adherent  Placenta 417 

I  i.  Placenta  Praevia 419 

CHAPTER  A^II. 

Obstructions  in  the  Parturient  Canal 420 

?  1 .  Displacements  o^  the  Uterus 420 

'i  2.  Abnormalities  of  the  Cervix 423 

?  3.  Obstruction  in  the  Vagina 427 

§  4.  Diseases  of  the  Vulva 428 

§  5.  Uterine  Tumors •  429 

§  6.  Ovarian  Tumors 432 

§  7.  Other  Abdominal  Tumors 433 

§  8.  Vaginal  and  Vulvar  Tumors 433 

CHAPTER  IX. 

Deformities  of  the  Pelvis 436 

A.  Common  Deformities 444 

?  1.  Generally  Equally  Contracted  Pelvis 444 

^  2.  Flat  Pelvis 448 

g  3.  Generally  Contracted  Flat  Pelvis 456 

§  4.  Pelvis  Flattened  by  Dislocation  of  both  Femora 456 

?  5.  Dangers  for  the  Mother  in  Cases  of  Contracted  Peh-is 458 

§  6.  Dangers  for  the  Foetus  in  Contracted  Pelvis 459 

?  7.  Treatment   of    Labor   in   Flat    or   Generally   Contracted    Flat 

Pehds -463 

B.  Rarer  Deformities  of  the  Pelvis 467 

^  1.  Asymmetric  Pelvis 467 

1.  Scoliotic  and  Scoliotic-Rhachitic  Pelvis 467 

2.  Obliquely  Contracted  Pelvis,  or  Naegele  Pelvis 468 

3.  Coxalgic  Pelvis , 471 

I  2.  Transversely  Contracted  Pelvis 474 

1.  Ankylosed  Transversely  Contracted  Pelvis 475 

2.  Kyphotic  Pelvis 476 

3.  Funnel-Shaped  Pelvis 481 

g  3.  Incurved  Pelvis 482 

1.  Osteomalacic  Pelvis 483 

2.  Pseudo-Osteomalacic  Rhachitic  Pelvis 489 

?  4.  Spondylolisthesis 490 

I  5.  Pelvis  Contracted  by  Tumors  springing  from  the  Pelvic  Bones.  493 
§  6.  Split  Pelvis 494 

1.  Pelvis  Split  at  Symphysis  Pubis 494 

2.  Pelvis  Split  at  Sacrum 496 

l  7.  Too  Wide  Pelvis 496 


CONTENTS.  xiii 

CHAPTER  X. 

Hemorrhage 496 

^  1.  Placenta  Praevia. 496 

^  2.  Premature  Detachment  of  Normally  inserted  Placenta 505 

I  3.  Rupture  of  the  Circular  Sinus  of  the  Placenta 507 

?  4.  Rupture  of    Umbilical   Vessels    in   Velamentous    Insertion  of 

Cord 509 

§  5.  Post-partum  Hemorrhage 509 

^  6.  Inversion  of  the  Uterus 516 

§  7.  Thrombus,  or  Hsematoma,  of  the  Vulva  and  Vagina 521 

§  8.  Thrombus,  or  Htematoma,  of  the  Cervix 523 

^  9.  Childbirth  without  Loss  of  Blood 524 

CHAPTER   XI. 
Eclampsia 525 

CHAPTER  XII. 
Heart  Disease 525 

CHAPTER  XIII. 

Rupture  of  Organs 525 

§  1.  Rupture  of  the  Uterus 525 

§  2.  Pressure  Necrosis  of  the  Uterus  or  Vagina 532 

§  3.  Laceration  of  the  Cervix  Uteri 534 

§  4.  Laceration  of  the  Vagina 535 

§  5.  Laceration  of  Vulva  and  Perineum 536 

I  6.  Rupture  of  Spleen,  Heart,  Blood-vessels,  or  Psoas  Muscle 546 

CHAPTER  XIV. 
Separation  of  Articulations 546 

CHAPTER  XV. 
Fractures  of  Bones 547 

CHAPTER  XVI. 
Sudden  Death  op  the  Mother  during  Labor 548 

CHAPTER   XVII. 
Childbirth  after  the  Death  of  the  Mother 550 

CHAPTER   XVIII. 

Injury  to  the  Fcetus  during  Labor 552 

§  1.  Cephalsematoma 553 

^  2.  Asphj'xia 555 

i  3.  Avulsion  of  the  Head 563 


xiv  CONTENTS. 

PART   III.— OBSTETRIC    OPERATIONS. 

CHAPTER  I. 
Tamponade 565 

CHAPTER  II. 
Artificial  Dilatation  of  the  Cervix  during  Pregnancy 566 

CHAPTER  HI. 
Curettage 569 

CHAPTER  IV. 
Induction  op  Premature  Labor 572 

CHAPTER  V. 
Vaginal  and  Intra-Uterine  Injections 577 

CHAPTER  VI. 
Intravenous  and  Subcutaneous  Injections 581 

CHAPTER  VII. 

Artificial  Dilatation  of  the  Cervix  during  Labor 583 

CHAPTER   VIII. 
Expression  of  the  Fcetus '.....  589 

CHAPTER  IX. 
Preparation  for  Operations 590 

CHAPTER  X. 
Forceps  Delivery 594 

CHAPTER  XL 

Version 618 

g  1.  By  the  External  Method 618 

I  2.  By  the  Internal  Digital  Method 619 

?  3.  By  the  Internal  Manual  Method 623 

?  4.  Cephalic  Version 624 

§  5.  Pelvic  Version 626 

§  6.  Podalic  Version 627 

CHAPTER  XII. 

Symphyseotomy 637 

Pubiotomy 651 

Ischiopubiotomy ' 654 

Bibliographic  References 656 

CHAPTER  XIII. 
Gastro-Elytrotomy 657 


CONTENTS.  XV 

CHAPTER  XIV.  PAGE 

CESAREAN  Section , 658 

CHAPTEE  XY. 
Utero-Ovaeian  Amputation 670 

CHAPTER  XVI. 

Panhysterectomy 674 

^  1.  Abdominal  Hysterectomy 674 

§  2.  Vaginal  Hysterectomy 675 

CHAPTER  XVII. 

Embryotomy 677 

I  1.  Craniotomy 677 

I  2.  Decapitation 685 

?  3.  Evisceration 686 

§  4.  Brachiotomy 687 

§  5.  Cleidotomy. 687 

PART    IV.— ABNORMAL    PUERPERY. 

CHAPTER  I. 

Puerperal  Infection 688 

§  1.  Nature  of  the  Disease 688 

g  2.  Etiology 695 

§  3.  Pathology 702 

§  4.  Symptoms,  Diagnosis,  and  Prognosis 707 

^doeitis  and  Colpitis 707 

Endometritis  and  Metritis 708 

Salpingitis  and  Oophoritis 709 

Parametritis  (Cellulitis  of  the  Pelvis) 709 

Lymphangeitis  and  Lymphothrombosis 710 

Peritonitis 711 

Pleurisy 713 

Pneumonia 713 

Pericarditis 713 

Phlegmasia  Alba  Dolens 713 

Phlebitis 714 

Endocarditis 716 

Disturbances  in  the  Alimentary  Canal 717 

Nephritis 717 

Disturbances  in  the  Nervous  System 717 

Arthritis 718 

Phlegmon  ( Cellulitis  of  the  Limbs ) 718 

Skin  Diseases 718 

Acutest  Septicaemia 718 

Mortality 719 

Gonorrhceic  Infection 719 

§  5.  Treatment 720 

I.  Prevention  of  Puerperal  Infection  in  Hospitals 723 

11.  Prevention  of  Puerperal  Infection  in  Private  Practice.  726 

III.  Curative  Treatment  of  Puerperal  Infection 728 

Bibliographic  References 746 


xvi  CONTENTS. 

CHAPTER   II.  ^    „ 

PAGE 

Diseases  of  the  Uterus 747 

I  1.  Subinvolution  of  the  Uterus 7-17 

I  2.  Superinvolution  of  the  Uterus 7.50 

I  3.  Retention  of  Parts  of  Placenta  or  Membranes 751 

§  4.  Malignant  Tumor  of  Pregnancy 752 

I  5.  Secondary  Post-partum  Hemorrhage ■ . .  755 

§  6.  Displacements 755 

CHAPTER  III. 

EiBROiDS  OF  THE  Abdomtn-al  "Wall 758 

CHAPTER  1\. 

Diseases  of  the  Breasts 758 

I  1.  Anomalous  Milk  Secretion 758 

?  2.  Sore  Xipples 761 

?  3.  Deep  Inflammation  of  the  ^'ipples 764 

§  4.  Eczema  of  the  Areola 765 

?  5.  Cellulitis  and  Adenitis  of  the  Areola 765 

I  6.  Erysipelas  of  the  Breasts 765 

§  7.  LymiDhangeitis  of  the  Breasts 766 

I  8.  Mastitis 766 

§  9.  Swelling  and  Milk  Retention  in  the  Axilla 773 

§  10.  Fistulfe  of  the  Breasts 774 

I  11.  Galactocele 774 

I  12.  Hypertrophy  of  the  Breasts 775 

CHAPTER   A\ 

Diseases  of  the  Uropoietic  Organs 776 

I  1.  Retention  of  Urine 776 

I  2.  Incontinence 777 

I  3.  Cystitis 777 

I  4.  Fistula} , 778 

CHAPTER  YI. 

Diseases  of  the  Circulatory  Organs 781 

?  1.  Embolism  and  Thrombosis  of  Arteries 781 

?  2.  Thrombosis  and  Embolism  of  the  Venous  System  ;  Heart-Clot...  782 

'i  3.  Entrance  of  Air  into  Uterine  Veins 786 

I  4.  Gangrene  of  the  Legs 787 

?  5.  Anaemia 788 

CHAPTER   VII. 

Diseases  of  the  Xervous  SYSTE>r 789 

?  1.  Xeuralgia  and  Pressure  Paralysis 789 

i  2.  Xeuritis  and  Polyneuritis 789 

?  3.  Tetanus  and  Tetanoid  Contractions 791 

I  4.  Eclampsia 795 

I  5.   Insanity 795 


CONTENTS.  xvii 

CHAPTER  YIII.  p^^.^ 


Eruptive  Fevees. 


CHAPTER  IX. 
(Jthee  Fevers 800 


PART    v.— NOTES    ON    DISEASES    OF    NEW-BORN    CHILDREN. 

CHAPTER  I. 

Diseases  of  the  Navel 801 

\  1.  Umbilical  Fungus 801 

?  2.  Umbilical  Hemorrhage 801 

\  3.  Umbilical  Arteritis 802 

I  4.  Umbilical  Phlebitis 802 

§  5.  Gangrene 802 

CHAPTER   11. 
Puerperal  Infectiox 802 

CHAPTER  III. 

GoxoRRHffiAL  Infection 803 

\  1.  Ophthalmia  Xeonatorum 803 

§  2.  Gouorrhoeal  Stomatitis 806 

\  3.  Gonorrhoeal  fl^doeocolpitis 806 

CHAPTER  IV. 

Diseases  of  the  jNIouth 806 

I  1.  Sprue 806 

§  2.  Bednar's  Aphthae 807 

?  3.  Injury  to  Epithelial  Pearls 808 

CHAPTER  Y. 

Glandular  Swellings 809 

I  1.  Mastitis 809 

\  2.  Hypertrophy  of  the  Thymus  Gland 810 

CHAPTER   VI. 

Skin  Diseases 810 

\  1.  Erythema 810 

\  2.  Eczema 811 

I  3.  Miliaria  ;  Pemphigus 811 

I  4.  Erysipelas 812 

\  5.  Ichthyosis 813 

\  6.  Sclerema 813 

CHAPTER  VII. 

Diseases  of.  the  Digestive  Organs 814 

\  1.  Cohc 814 

\  2.  Constipation 815 

I  3.  Diarrhfjea 815 

\  4.  Icterus 817 

B 


xviii  '     CONTENTS. 

CHAPTEE  VIII.  p^3j. 

Tetanus 817 

CHAPTER  IX. 

Diseases  of  the  Air-Passages 818 

I  1.  Nasal  Catarrh 818 

I  2.  Catarrhal  Laryngitis 819 

§  3.  Atelectasis 819 

CHAPTER  X. 

Congenital  Diseases  of  the  Heart  and  Large  Blood- Vessels 820 

CHAPTER   XL 
Cyanosis 820 

CHAPTER  XII. 
Hereditary  Syphilis 821 

CHAPTER  XIII. 

Hemorrhage 824 

I  1.  Hemorrhage  from  the  Vagina 824 

§  2.  Hemorrhage  from  the  Intestinal  Tract ;  Melsena 824 

§  3.  Hemorrhage    from    the    Kidneys ;     Acute    Heemoglobinuria ; 

Winckel's  Disease 825 

§  4.  Acute  Fatty  Degeneration  ;  Buhl's  Disease 825 

§  5.  Pulmonary  Apoplexy 826 

CHAPTER  XIV. 

Deformities • 826 

I  1.  Harehp 826 

I  2.  Cleft  Palate 826 

§  3.  Tongue-Tie,  or  Ankyloglossum 826 

I  4.  Encephalocele,  or  Hernia  Cerebri ;  Meningocele 826 

§  5.  Spina  Bifida,  or  Hydrorrhachis 827 

g  6.  Umbilical  Hernia 828 

g  7.  Atresia  Ani 829 

CHAPTER   XV. 
Sudden  Death  of  the  Xew-Born  Child 830 


LIST  OF  ILLUSTRATIONS 


Foundation. 

Figure  page 

1.  Ovary  of  human  foetus  of  ten  or  eleven  weeks 3 

2.  Part  of  ovary  near  surface,  from  human  foetus  of  sixteen  weeks 3 

3.  Part  of  ovary  near  surface,  from  human  foetus  of  twenty-eight  weeks 3 

4.  Part  of  ovary  near  surface,  from  human  foetus  of  thirty-six  weeks 4 

5.  Part  of  section  from  surface  to  hilum  of  ovary  of  girl  three  days  old 4 

6.  Section  of  ovary  of  bitch  six  months  old 4 

7.  Graafian  follicles  from  new-born  child 5 

8.  Graafian  follicle  from  girl  seven  months  old 5 

9.  Primordial  ova  undergoing  division 6 

10.  Ovary  and  tube,  nineteen-year-old  girl 6 

11.  Ovarj''  and  tube,  girl  twenty-four  years  old 7 

12.  Section  of  ovary  of  cat,  enlarged  six  times 8 

13.  Part  of  same,  enlarged  twenty-four  times 8 

14.  Section  of  ovary  of  woman  twenty-two  days  after  menstruation 9 

15.  Section  of  ovary  of  a  woman  on  the  first  day  of  menstruation 9 

16.  Perpendicular  section  of  the  cortical  substance  of  the  ovary :   A,  new- 

born ;  B,  four  years  old  ;  C,  twenty  years  old 10 

17.  Young  Graafian  follicle,  pig 10 

18.  Follicle  in  middle  stage,  pig 11 

19.  Ovary,  woman,  fresh  corpus  luteum 11 

20.  Human  ovum 12 

21.  Uterus  during  menstruation 14 

22.  Section  of  endometrium,  menstruating  woman 15 

23.  Fibre  of  endometrium 16 

24.  Vessels  of  the  vagina  and  internal  genitals  in  their  relation  to  the  super- 

ficial muscular  structures 18 

25.  Hymen  with  linear  opening 19 

26.  Annular  hymen 19 

27.  Crescent-shaped  hymen 20 

28.  Indented  hymen 20 

29.  Ruptured  hymen 21 

30.  Human  spermatozoids 22 

31.  Fecundation  of  ovum  of  mouse 23 

32.  Fecundation  of  ovum  of  mouse 23 

33.  Fecundation  of  ovum  of  mouse 23 

34.  Fecundation  of  ovum  of  mouse 23 

35.  Fecundation  of  ovum  of  mouse 23 

36.  Fecundation  of  ovum  of  mouse 23 

37.  Fecundation  of  ovum  of  mouse 24 

38.  Fecundation  of  ovum  of  mouse 24 

39.  First  stages  of  segmentation  in  rabbit 25 

40.  Later  stages  of  segmentation  in  rabbit 25 

xix 


XX  LIST   OF   ILLUSTRATIONS. 

Normal  Pregnancy. 
Figure  page 

41.  Section  of  decidua  of  pregnancy 28 

42.  Uterus  of  woman,  decidua  in  beginning  pregnancy 28 

43.  Embedding  of  human  ovum 29 

44.  Pregnant  uterus,  twenty-fifth  day  ;  decidua  vera  and  refiexa 30 

45.  Human  ovum,  two  weeks  old,  villi  and  embryo 31 

46.  Blood-vessels  of  villus 32 

47.  First  connection  between  ovum  and  uterine  epithelium,  monkey  33 

48.  First  insertion  of  villi  in  decidua 33 

49.  Structure  of  human  placenta 34 

50.  Villi  bathed  in  maternal  blood 35 

51.  Transverse  section  of  villus  at  term 35 

52.  Transverse  section  through  front  end  of  primitive  streak  and  blastoderm 

of  chick 36 

53.  Transparent  area  of  blastoderm  of  chick,  very  early,  commencement  of 

primitive  streak 37 

54.  Pyriform  transparent  area  of  chick's  blastoderm  with  primitive  groove.  ...  37 

55.  Blastoderm  of  chick,  eighteen  hours 38 

56.  Transverse  section  through  chick  before  and  after  closure  of  medullary 

canal 38 

57.  Five  figures  showing  development  of  membranes  39 

68.  Longitudinal  vertical  section  of   chick  and  neighboring  parts  of   blasto- 
derm, fourth  day 40 

59.  Longitudinal  section  through  posterior  part  of  chick,  third  day  ;  beginning 

allantois 41 

60.  Formation  of  umbilical  cord  and  its  central  insertion 42 

61.  First  circulation  in  vascular  area  of  yolk-sac 47 

62.  Same,  a  little  later 48 

63.  Second,  or  placental,  circulation 48 

64.  Fetal  heart  and  chief  blood-vessels 48 

65.  Spee's  ovum,  second  week,  embrj^o  in  side  view 55 

66.  Same  embryo  from  above 55 

67.  Same  ovum,  showing  relations  to  chorion 55 

68.  Same  ovum,  embryo  in  longitudinal  section 55 

69.  Older  human  ovum  of  Spee 55 

70.  Same  in  longitudinal  section 55 

71.  Human  ovum  and  embryo,  from  twelve  to  thirteen  days,  Allen  Thomson. .  56 

72.  Human  ovum  and  embryo,  fourteen  days,  Allen  Thomson 56 

73.  Human  embryo,  less  than  fourteen  days.  His 56 

74.  Human  embryo,  between  sixteen  and  eighteen  days,  His 56 

75.  Human  embryo,  three  weeks,  Allen  Thomson 57 

76.  Human  embryo,  four  weeks,  Allen  Thomson 57 

77.  Human  ovum  with  embryo,  four  weeks,  Waldeyer 57 

78.  Human  ovum,  end  of  first  month 57 

79.  Gravid  uterus,  woman,  ovum  and  embryo,  five  weeks 58 

80.  Human  embryo,  beginning  of  second  month,  from  eight  to  ten  millimetres 

long 59 

81.  Human  embryo,  nearly  five  weeks 59 

82.  Human  embryo,  six  weeks 59 

83.  Human  embryo,  about  seven  weeks 59 

84.  Human  embryo,  about  eight  weeks 60 

85.  Human  ovum  and  foetus,  end  of  the  second  month 60 


LIST   OF   ILLUSTRATIONS.  xxi 

FiGtTRE  ■                                                                                                                                                                                      PAGE 

86.  Human  foetus,  fourth  month 61 

87.  Human  foetus,  end  of  fourth  month 62 

88.  Human  foetus,  fifth  month 62 

89.  Horizontal  circumference  of  head 65 

90.  ]Microscopical  elements  in  liquor  amnii 67 

91.  Liquor  amnii  cells  treated  with  ether 67 

92.  Placenta,  fetal  surface 68 

93.  Placenta,  maternal  surface 69 

94.  Insertion  of  placenta 69 

95.  Doable  placenta 69 

96.  Battledoor  placenta 70 

97.  Velamentous  insertion  of  cord 70 

98.  Origin  of  velamentous  insertion 70 

99.  Origin  of  velamentous  insertion 70 

100.  Transverse  section  of  umbilical  cone 71 

101.  Transverse  section  of  umbilical  cord 71 

102.  Capillaries  at  boundary-line  between  abdominal  umbilicus  and  cord 71 

103.  Fold  of  Schultze 72 

104.  Vessels  of  umbilical  cord 72 

105.  Umbilical  vesicle  and  omphalomesenteric  vessels 73 

106.  Attitude  of  foetus  at  term,  vertex  presentation,  left  occipito-anterior  posi- 

tion     76 

107.  Face  presentation,  left  mento-anterior  position 77 

108.  Breech  presentation 78 

109.  Knee  presentation 79 

110.  Foot  presentation 80 

111.  Shoulder  presentation,  dorsoposterior  position 81 

112.  Shoulder  presentation,  dorso-anterior  position 82 

113.  Effect  of  gravity  on  foetus  in  globular  uterus  during  early  pregnancy 83 

114.  Effect  of  gravitj^  on  foetus  at  end  of  pregnancy 83 

115.  Virgin  uterus,  natural  size 84 

116.  Size  of  uterus  at  the  end  of  each  calendar  month  of  pregnancy 85 

117.  Uterine  muscle-cells 85 

118.  Uterus  at  term,  in  situ 86 

119.  Musculature  of  pregnant  uterus,  side  view 87 

120.  Musculature  of  pregnant  uterus,  front  view 88 

121.  Inner  muscular  layer  of  pregnant  uterus 89 

122.  Longitudinal    section    through    lower    uterine    segment  of    a  pregnant 

uterus 90 

123.  Same  with  muscular  lamellae  pulled  apart 90 

124.  Similar  section  showing  shortening  of  musculature  after  birth 90 

125.  Uterus  and  foetus  at  the  end  of  pregnancy 91 

126.  Blood-vessels  of  pregnant  uterus 92 

127.  Nerves  of  pregnant  uterus 93 

128.  Course  of  ureter,  end  of  pregnancy 94 

129.  Vulva,  anterior  wall  of  vagina  bulging  out 92 

130.  Breast  of  blonde  outside  of  pregnancy 93 

131.  Breast  of  blonde  during  pregnancy 93 

132.  Breast  of  brunette  outside  of  pregnancy 94 

133.  Breast  of  brunette  during  pregnancy 94 

134.  Acinus  of  mammary  gland,  girl  sixteen  years 95 

135.  Acini,  girl  eighteen  years 95 


xxii  LIST    OF    ILLUSTRATIONS. 

FlGITEE  PAGE 

136.  Mammary  gland  during  lactation 96 

137.  Abdominal  striae 96 

138.  Colostrum 96 

139.  Longitudinal  section  through  body  of  woman  at  term 99 

140.  Hysterical  tympanites 106 

141.  Same  patient  anaesthetized 106 

142.  Examination-table 108 

143.  Dorsal  position 108 

144.  Palpating  fundus  uteri,  seventh  month 109 

145.  Palpating  back  of  foetus 110 

146.  Palpating  head  with  both  hands Ill 

147.  Palpating  head  with  one  hand  from  above 112 

148.  Palpating  head  from  below 113 

149.  Small  fetal  parts  turned  against  anterior  wall 114 

150.  Bimanual  examination 115 

151.  Internal  pelvimetry 116 

152.  Harris's  pelvimeter 116 

153.  Ehomb  of  Michaelis 117 

154.  Brewer's  speculum 117 

155.  Sims's  speculum 118 

156.  Sims's  position 118 

157.  Introduction  of  Sims's  speculum 119 

158.  Hunter's  depressor 119 

159.  Garrigues's  depressor 120 

160.  How  to  hold  Garrigues's  depressor  with  speculum 120 

161.  Hymen  of  woman  who  has  borne  one  child 121 

162.  Hypertrophy  of  vaginal  portion  in  virgin,  simulating  laceration  of  cervix  122 

163.  Sagittal  section  of  a  primigravida  during  last  month 123 

164.  Sagittal  section  of  a  plurigravida  during  last  month 124 

Normal  Labor. 

165.  Anterior  surface  of  the  sacrum  and  coccyx 131 

166.  Posterior  surface  of  the  sacrum  and  coccyx 131 

167.  Lateral  edge  of  the  sacrum 132 

168.  Sacral  canal 132 

169.  Hip-bone,  outer  surface 133 

170.  Hip-bone,  inner  surface 134 

171.  Horizontal  section  through  sacro-iliac  articulation 135 

172.  Oscillatory  movement  of  the  sacrum 136 

173.  Ligaments  of  the  pelvis 136 

174.  Horizontal  section  through  symphysis  pubis 137 

175.  Bony  pelvis,  from  above 138 

176.  Pelvic  inlet 139 

177.  Pelvic  outlet 140 

178.  Inclination  of  the  pelvis 142 

179.  Axis  of  pelvis 143 

180.  Pelvis  of  new-born  child 145 

181.  Pelvis  of  child 146 

182.  Horizontal  section  through  pelvis  of  new-born  child 146 

183.  Horizontal  section  through  pelvis  of  adult  woman 146 

184.  Pelvis  covered  with  muscles 148 


LIST   OF   ILLUSTRATIONS.  xxiii 

Figure  -                                                                                                                           page 

185.  Posterior  wall  of  pelvic  cavitj',  with  pyriformis  nmscles  and  sacro-iliac 

ligaments 149 

186.  Side  view  of  pelvic  cavity,  with  obturator  iuternus  muscle  and  sacro- 

sciatic  ligaments 149 

187.  Muscles  of  the  perineum 150 

188.  Levator  ani  muscle,  from  below 151 

189.  Side  view  of  levator  ani 152 

190.  Pelvic  and  perineal  fascise 1,53 

191.  Genital  canal  before  labor,  pluripara 154 

192.  Genital  canal  after  the  dilatation  of  the  lower  uterine  segment  and  the 

cervical  canal,  pluripara 154 

193.  Section  through  lower  uterine  segment 154 

194.  Boundary-line  of  insertion  of  ovum 154 

195.  Parturient  canal I55. 

196.  Fetal  head,  front  view 156. 

197.  Fetal  head,  side  view 157 

198.  Fetal  head,  from  above 158 

199.  Fetal  head,  from  behind 159 

200.  True  pelvis,  life  size ". 160' 

201.  Dilatation  of  cervix  in  pluripara 167 

202.  Dilatation  of  cervix  in  pluripara 167 

203.  Dilatation  of  cervix  in  pluripara 167 

204.  Sagittal  section  through  body  of  quadripara,  stage  of  dilatation 168 

205.  Stage  of  expulsion 169 

206.  Head  pressing  on  perineum 171 

207.  Flexion  of  head 172 

208.  Internal  rotation  and  extension 173 

209.  Extension  of  head 174 

210.  Extension  of  head 174 

211.  Extension  of  head 174 

212.  External  rotation 175 

213.  Expulsion  of  placenta  according  to  Duncan 177 

214.  Expulsion  of  placenta  according  to  Baudelocque 177 

215.  Asymmetry  of  head  born  in  right  occipito-anterior  position 178 

216.  Caput  succedaneum 178 

217.  Hancks's  douche-pan 181 

218.  Fountain  syringe 182 

219.  Inflatable  rubber  cushion  with  apron 182 

220.  Davidson's  bulb  and  valve  syringe 183 

221.  Esmarch's  chloroform-mask 183 

222.  Patient  raised  on  chair,  head  up • 191 

223.  Patient  in  left-side  position , 192 

224.  Child  placed  in  front  of  mother's  genitals,  nurse  compressing  uterus, 

doctor  cutting  cord 195 

225.  Expression  of  the  placenta 197 

226.  Extraction  of  the  membranes 199 

227.  Abdominal  binder 200 

228.  Garrigues'  s  perineal  pad 201 

229.  Patient  with  all  bandages ; 202 

230.  New  York  Maternity  Hospital,  east  elevation 223 

231.  Same,  north  elevation 223 

232.  Same,  plan  of  ground  floor  224 


xxiv  LIST    OF   ILLUSTRATIONS. 

Normal  Puerpery. 

Figure  page 

233.  Microscopical  appearance  of  inside  of  uterus  immediately  after  delivery.   229 

234.  Sagittal  section  of  the  pelvic  organs  of  a  puerpera  on  the  second  day  after 

delivery 230 

235.  Sagittal  section  of  the  pelvic  organs  of  a  puerpera,  uterus  below  brim  . . .  231 

236.  Acini  of  mammary  gland  during  lactation 232 

237.  Microscopical  appearance  of  woman's  milk 233 

238.  Breast-pump 236 

239.  Garrigues's  breast-bandage 238,  239 

240.  Teufel's  abdominal  supporter 240 

241.  Soxhlet's  sterilizer 250 

242.  Tarnier's  incubator,  exterior 254 

243.  Same,  interior 255 

244.  Same,  hot-water  jug 255 

Abnormal  Pregnancy. 

245.  Acardiacus 259 

246.  Abortive  ovum  'expelled  with  decidua 264 

247.  Transverse  sections  of  the  genital  cord  of  a  cow 277 

248.  Ovaries,  tubes,  and  uterus,  human  embryo,  tenth  week 277 

249.  Urogenital  sinus  and  appendages,  human  embryo 277 

250.  Uterus  didelphys 278 

251.  Uterus  unicornis 280 

252.  Longitudinal  section  of  the  same 281 

253.  Interstitial  inflammation  of  decidua 283 

254.  Endometritis  tuberosa  and  polyposa 284 

255.  Fritsch's  urethral  syringe 286 

256.  Oidium  albicans 287 

257.  Trichomonas  vaginalis 287 

258.  Vulvar  vegetations 290 

259.  Impaction  of  retroflexed  gravid  uterus 298 

260.  Genupectoral  position 299 

261.  Hodge-Emmet  pessary 299 

262.  Interstitial,  or  tubo-uterine,  pregnancy 303 

263.  Interstitial  pregnancy 804 

264.  Pregnancy  in  rudimentary  horn  of  uterus  unicornis 305 

265.  Tubal  pregnancy 306 

266.  Intraligamentous  tubal  pregnancy 307 

267.  Syphilitic  villus  of  the  chorion 341 

268.  Villi  from  line  of  demarcation  between  healthy  and  diseased  placental 

tissue 342 

269.  Amniotic  bands  extending  from  foetus  to  amnion 346 

270.  Amniotic  bands  encircling  legs  of  foetus 347 

271 .  Intra-uterine  amputation 347 

272.  Cystic  degeneration  of  villi 350 

273.  Uterus  containing  vesicular  mole 351 

274.  Imperfect  development  of  reflexa 352 

275.  Apoplectic  ovum 353 

276.  Fleshy  mole 353 

277.  True  knot  of  cord 355 

278.  Torsion  of  cord 356 


LIST    OF    ILLUSTRATIONS.  XXV 

Abnormal  Labor. 

Unfavorable  Position,  Presentation,  or  Attitude. 

Figure  page 

279.  Birth  in  occipitoposterior  position 8B3 

280.  Shape  of  fetal  head,  in  persistent  occipitoposterior  position ,364 

28L  Shape  of  head  of  child  born  in  occipito-anterior  position,  vertex  presen- 
tation    364 

282.  Face  presentation  due  to  lateroversion  of  uterus 368 

283.  Face  presentation,  extension  and  descent 369 

284.  Face  presentation,  rotation  forward,  of  chin  and  flexion 370 

285.  Face  presentation  in  the  distended  vulva 371 

286.  Face  presentation,  persistent  mentoposterior  position 372 

287.  Shape  of  skull,  face  presentation 373 

288.  Attitude  of  child  born  in  face  presentation 373 

289.  Thorn's  method,  of  changing  face  into  vertex  presentation 374 

290.  Head  of  child  born  in  brow  presentation 375 

291.  Lateral  flexion  of  fetal  body  in  pelvic-end.  presentation 377 

292.  Normal  birth  of  head  in  pelvic-end  presentation 378 

293.  Head  flexed  in  pelvic-end  presentation 378 

294.  Legs  extended  in  front  of  foetus  in  breech  presentation 379 

295.  Irregular  disengagement  of  head,  pelvic-end  presentation 380 

296.  Liberating  posterior  arm,  breech  presentation 382 

297.  Dorsal  displacement  of  arm  across  neck,  pelvic  presentation 383 

298.  Smellie's  method  of  delivering  after-coming  head 384 

299.  Prague  method  of  delivering  after-coming  head,  first  step 385 

300.  Prague  method,  second  step 386 

301.  Mode  of  passing  fillet  over  foot 387 

302.  Olivier's  fillet-carrier 388 

803.     Fillet  in  groin  in  sacro-anterior  position 388 

304.  Fillet  on  thigh  in  sacroposterior  position 389 

305.  Blunt  hook 389 

306.  Tarnier  forceps  applied  to  breech  in  transverse  diameter 390 

307.  Shape  of  after-coming  head 391 

308.  Prolapse  of  arm  in  transverse  presentation 394 

309.  Spontaneous  evolution,  first  step 394 

310.  Spontaneous  evolution,  second  step 394 

311.  Spontaneous  evolution,  third  step 394 

312.  Spontaneous  evolution,  fourth  step 394 

313.  Dorsal  displacement  of  arm,  vertex  presentation 397 

Excessive  Size  of  Foetus. 

314.  Hydrocephalus 399 

315.  Skeleton  of  hydrocephalic  foetus 400 

316.  Congenital  cystic  elephantiasis 401 

317.  Foetus  with  distended  bladder 401 

318.  Spina  bifida 402 

319.  Hemicephalus 402 

Twin  Labor. 

320.  Twins,  vertex  presentation 404 

321.  Twins,  one  vertex,  the  other  breech  presentation 405 

322.  Locked  twins,  both  head  presentation 406 

323.  Locked  twins,  breech  and  head  presentations 407 


xxvi  LIST    OF    ILLUSTRATIONS. 

Double  Monstrosities. 

Figure  page 

324.  Dicephalus 408 

325.  Thoracopagi  dissected 409 

326.  Rose-Marie,  dicephalus 410 

327.  Thoracopagi 411 

328.  Ischiopagae 411 

Abnormalities  of  Ovum. 

329.  Eepositor  for  prolapsed  umbilical  cord 416 

330.  Elevated-pelvis  position  on  inverted  chair 416 

331.  Retained  placenta 418 

Obstructions  in  the  Parturient  Canal. 

332.  Anterior  sacculation  of  uterus 421 

333.  Posterior  sacculation  of  uterus 422 

334.  Partial  prolapse  of  gravid  uterus 423 

335.  Prolapse  and  hypertrophy  of  cervix,  head  presentation 423 

336.  Conglutination  of  the  external  os 424 

337.  Cervix-scissors 427 

338.  Pediculated  myoma  obstructing  labor 429 

339.  Retrocervical  fibromyoma  filling  pelvis    430 

340.  Head  arrested  at  brim  by  ovarian  cyst 432 

341.  Fibrous  polypus  of  cervix  occupying  vagina 434 

Deformities  of  Pelvis. 

342.  Relation  between  the  diagonal  conjugate  and  the  available  conjugate  . . .  441 

343.  Relation  between  the  diagonal  conjugate  and  the  available  conjugate  . . .  441 

344.  Relation  between  the  diagonal  conjugate  and  the  available  conjugate  . . .  441 

345.  Double  promontory 441 

346.  Generally  contracted  pelvis,  male  type,  from  above 445 

347.  Same,  front  view 446 

348.  Adult  pelvis  with  infantile  type 447 

349.  Pelvis  of  reclination 447 

350.  Simple  flat  pelvis 448 

351.  Rhachitic  flat  pelvis 449 

352.  Rhachitic  flat  pelvis  with  strongly  curved  sacrum 450 

353.  Rhachitic  flat  pelvis  with  convex  sacrum 450 

354.  Rhachitic  pelvis  with  heart-shaped  brim 451 

355.  Rhachitic  skeleton 452 

356.  Engagement  of  vertex  in  flat  pelvis 453 

357.  Pelvis  with  dislocation  of  both  femora 457 

358.  Deep  depressions  on  presenting  head 460 

359.  Deep  depressions  on  after-coming  head 460 

360.  Pressure  marks  on  skin  of  skull  and  face 461 

361.  Scoliotic-rhachitic  pelvis 468 

362.  Obliquely  contracted  pelvis,  or  Naegele  pelvis 469 

363.  Coxalgic  pelvis 472 

364.  Ankylosed  transversely  contracted  pelvis,  or  Robert  pelvis 475 

365.  Kyphotic  pelvis  from  above  and  front 477 


LIST   OF   ILLUSTRATIONS.  xxvii 

Figure  -  page 

366.  Same  from  behind  and  below 478 

367.  Pelvis  obtecta 481 

368.  Funnel-shaped  pelvis 482 

369.  Vertical  section  of  osteomalacic  pelvis 483 

370.  Woman  with  osteomalacia 484 

371.  Osteomalacic  pelvis,  front  view 485 

372.  Same  from  below 485 

373.  Osteomalacic  pelvis 486 

374.  Pseudo-osteomalacic  pelvis,  front  view 489 

375.  Same  from  above 489 

376.  Spondylolisthetic  pelvis 490 

377.  Normal  lumbar  vertebra 491 

378.  Lumbar  vertebra  with  elongated  interarticular  portion 491 

379.  Patient  with  spondylolisthesis 492 

380.  Patient  with  spondylolisthesis 492 

381.  Patient  with  spondylolisthesis 492 

382.  Osteoma  of  sacrum 493 

383.  Enchondroma  of  sacrum 494 

384.  Pelvis  without  symphysis  pubis 495 

385.  Pelvis  without  sacrum 495 

Hemorrhage. 

386.  Central  placenta  prsevia 497 

387.  Cervical  placenta  preevia 499 

388.  Placenta  descending  to  boundary-line  of  greatest  expansion  of  os 501 

389.  Rupture  of  circular  sinus 508 

390.  Incomplete  inversion  of  uterus 517 

391.  Complete  inversion  of  uterus 518 

392.  Superficial  vaginal  haematoma 524 

Rupture  of  Organs. 

393.  Rupture  of  uterus 528 

394.  Pressure  necrosis  of  uterus 532 

395.  Laceration  of  perineum  and  vagina 537 

396.  Central  laceration  of  perineum 538 

397.  Serre-fine 542 

398.  Knee-bandage 544 

Injury  to  Child. 

399.  Double  cephalsematoma 554 

400.  Schultze's  swingings 560 

401.  Schultze's  swingings 560 

Operations. 
Dilatation  of  Cervix,  Curettage,  Induction  of  Premature  Labor,  Injections. 

402.  Hanks's  cervical  dilator 566 

403.  Goelet's  expanding  dilator 567 

404.  Garrigues's  olive-shaped  dilators 567 

405.  Robb's  leg-holder ,568 

406.  Garrigues's  weight  speculum 568 


xxviii  LIST    OF   ILLUSTRATIONS. 

FlGUEE  PAGE 

407.  Schroeder's  vaginal  retractor 568 

408.  Sims's  sharp  curette 569 

409.  Simon's  sharp  curette 569 

410.  Recamier's  dull  curette 569 

411.  Thomas's  large  dull  wire  curette 569 

412.  Placenta-forceps,  heart-shaped  jaws 570 

413.  Placenta-forceps,  oval  jaws 570 

414.  Garrigues's  single-current  soft-metal  intra-uterine  tube 571 

415.  Barnes's  cervical  dilators 573 

416.  Forceps  for  carrying  bags  or  gauze  into  the  uterus 574 

417.  Peterson's  colpeurynter .  .'. 575 

418.  Champetier  de  Ribes's  cervical  dilator 575 

419.  Bag  in  grip  of  forceps 576 

420.  Garrigues's  intra-uterine  glass  tube  with  attachment 577 

421.  Garrigues's  apparatus  for  transfusion  and  infusion 582 

422.  Philander  Harris's  method  of  manual  dilatation  of  the  cervix 585 

423.  Arthur  Miiller's  cervical  dilator 588 

424.  Hanging  posture  of  Walcher 592 

Forceps  Delivery. 

425.  A.  R.  Simpson's  axis-traction  forceps 595 

426.  Handle  of  the  same 595 

427.  Chamberlen's  forceps 596 

428.  Levret's  forceps 597 

429.  J.  Y.  Simpson's  forceps ■• 597 

430.  Naegele'  s  forceps 598 

431.  Lock  of  the  same 598 

432.  Elliott's  forceps 598 

433.  Hodge's  forceps 599 

434.  Tarnier's  forceps  held  as  used  for  traction 600 

435.  Same  without  the  traction-handle 600 

436.  A.  R.  Simpson's  new  model 602 

437.  Component  parts  of  the  same 602 

438.  Left  branch  of  forceps  guided  by  right  hand 608 

439.  Mode  of  holding  forceps  during  traction 609 

440.  Another  way  of  holding  forceps 610 

441.  Forceps  on  head  at  brim 612 

442.  Forceps  on  head  at  outlet 612 

443.  Axis-traction  forceps  held  with  full  hand  in  delivering  head 615 

444.  Facial  paralysis  of  new-born  child 617 

Version. 

445.  Cephalic  version  by  Braxton  Hicks' s  method 620 

446.  Podalic  version  by  Braxton  Hicks' s  method,  first  step 621 

447.  Podalic  version  by  Braxton  Hicks's  method,  second  step 622 

448.  Podalic  version  by  Braxton  Hicks's  method,  third  step 622 

449.  Podalic  version  by  Braxton  Hicks's  method,  fourth  step 623 

450.  Podalic  version  by  Braxton  Hicks's  method,  completed 624 

451.  Cephalic  version  by  Busch's  method    625 

452.  Cephalic  version  by  D'Outrepont's  method 626 

453.  Podalic  version  by  internal  manual  method,  head  presentation 630 


LIST    OF    ILLUSTRATIONS.  xxix 

Figure  -                                                                                                                  page 

454.  Podalic  version  with  prolapsed  arm 631 

455.  Way  of  seizing  foot 63 1 

456.  Seizing  leg  of  same  side  as  presenting  shoulder 632 

457.  Seizing  opposite  leg 632 

458.  Making  a  noose  with  one  hand,  first  step 633 

459.  Making  a  noose  with  one  hand,  second  step 633 

460.  Carrying  noose  on  fingers 634 

461.  Braun's  fillet-carrier,  or  repositor  for  prolapsed  cord 634 

462.  Routh's  fillet-carrier 635 

463.  Double  manoeuvre  for  dislodging  head 636 

Sympliyseotomy. 

464.  Veins  of  prevesical  space 644 

465.  Triangular  ligament  of  urethra 645 

466.  Diagram  of  fasciae  of  pelvic  floor 646 

467.  External  erectile  organs 647 

468.  Galbiati's  falcetta 648 

469.  Same,  modernized  648 

470.  Hay's  director 649 

471.  Harris's  method  of  opening  symphysis,  front  view 650 

472.  Same,  side  view 650 

473.  Curved,  probe-pointed  bistoury  used  in  Garrigues's  first  case 651 

474.  Garrigues's  symphyseotomy-bandage 653 

Embryotomy. 

475.  Naegele's  perforator 678 

476.  Thomas's  perforator 679 

477.  J.  Y.  Simpson's  cranioclast 680 

478.  Braun's  cranioclast 680 

479.  Braxton-Hicks's  cephalotribe 681 

480.  Thomas's  craniotomy-forceps 682 

481.  Tarnier's  basiotribe 683 

482.  A.  E.  Simpson's  basilyst 683 

483.  Crotchet 684 

484.  Braun's  key-hook 685 

485.  Same,  applied 686 

Abnormal  Puerpeey. 

486.  Dissecting  metritis 703 

487.  Lymphatics  of  uterus 704 

488.  Lymphangeitis  and  lymphothrombosis  of  uterus 705 

489.  Formalin  disinfector ...  723 

490.  Exploratory  vaginal  aspirator .' 736 

491.  Garrigues's  blunt  expanding  perforator 736 

492.  Sky-rocket  drainage-tube 736 

493.  Double  soft-rubber  drainage-tube  with  cross-bar 736 

494.  Deciduoma  malignum 752 

495.  Chorio-eplthelioma  malignum 753 

496.  Section  through  pelvic  organs  of  patient  with  chorio-epithelioma  malig- 

num of  uterus  and  vagina 754 

497.  Milk  of  anseniic  woman 760 


XXX  LIST   OF   ILLUSTRATIONS. 

Figure  page 

498.  Milk  of  woman  fifteen  months  after  childbirth 760 

499.  Nipple-shield 763 

500.  Another  nipple-shield 763 

501.  Glandular  mastitis  forming  abscess 767 

502.  Desmarre's  eyelid  retractors '805 

503.  Director  for  tongue-tie 826 

504.  Navel  button 829 


TEXT-BOOK  OF   OBSTETRICS 


NORMAL    DIVISION. 


PART   I.— FOUNDATION. 

The  science  of  obstetrics  is  ttie  knowledge  of  the  history  of  man 
from  the  moment  of  his  conception  to  the  time  he  is  weaned,  includ- 
ing diseases  commonly  observed  during  the  first  few  days  of  the  child's 
life  ;  but,  as  a  rule,  information  about  the  child  in  health  and  disease 
after  its  mother  recovers  from  childbirth  is  left  to  works  on  hygiene 
and  paediatrics.  Obstetrical  art  is  the  aid  to  be  given  to  mother  and 
child  during  pregnancy,  labor,  and  the  puerperal  state.  The  word 
obstetrics  is  derived  from  the  two  Latin  words  ob  and  store,  to  stand 
in  front  of,  referring  to  the  position  of  the  obstetrician  in  Rome, 
where  women  were  delivered  sitting  on  a  chair  made  for  that  purpose. 


CHAPTER    I. 
PUBERTY. 


Woman  can  conceive  only  during  a  certain  part  of  her  life.  Puberty 
and  the  climacteric  mark  the  beginning  and  the  end  of  her  fruitful 
period.  Puberty  is  the  change  from  childhood  to  womanhood.  It  is 
a  gradual  development  which  generally,  in  the  temperate  zone,  takes 
place  in  the  fourteenth  or  fifteenth  year  of  the  girl's  life.  At  that 
time  the  breasts  become  larger,  the  uterus  increases  in  size,  the  hips 
become  broader,  and  the  contour  of  the  whole  body  is  rounded  out  by 
an  increase  of  adipose  tissue.  The  external  genitals  and  the  armpits 
become  covered  with  a  growth  of  hair,  menstruation  appears,  and  the 
two  sexes,  who  hitherto  rather  shunned  and  even  despised  each  other, 
now  begin  to  feel  a  mutual  attraction. 

1 


2  OBSTETRICS— FOUNDATION. 

CHAPTER     II. 
NUBILITY. 

Though  puberty  ushers  in  the  period  when  woman  can  conceive, 
it  does  not  follow  that  it  would  be  proper  and  desirable  for  her  to  be- 
come impregnated  at  this  early  stage  of  development.  For  instance, 
in  East  India,  where  child  marriages  are  practised  on  religious  grounds, 
they  often  lead  to  sterility ;  and  even  in  our  own  latitudes  statistics 
show  a  much  larger  mortality  among  married  women  under  twenty 
years  of  age  than  later.  It  is  evidently  against  the  laws  of  nature  for 
a  woman  to  become  a  mother  before  her  own  body  is  fully  de\' eloped. 
The  uterus  should  have  reached  the  size  it  has  in  the  adult ;  the  pelvis 
should  have  acquired  the  necessary  dimensions  for  the  safe  passage 
of  a  child  through  its  canal ;  the  abdominal  muscles  should  be  strong 
enough  to  assist  the  uterus  in  bringing  forth  the  fruit  from  its  interior 
to  the  surrounding  world  ;  and  the  breasts  should  be  fit  to  nurse  the 
child  after  its  severance  from  the  maternal  body ;  not  to  speak  of 
the  mental  maturity  that  is  requisite  for  bringing  up  a  child  in  a 
civilized  community.  It  may,  therefore,  be  stated  in  a  general  way 
that  most  women  should  not  marry  before  they  are  twenty  years  old. 

Generally  the  fruitful  period  of  woman  comprises  about  thirty 
years,  between  the  ages  of  fifteen  and  forty-five  years  ;  but  exception- 
ally pregnancy  and  childbirth  are  observed  much  earlier  or  later  than 
these  limits.  The  writer  has  examined  a  girl  at  full  term  who  was 
only  thirteen  years  old,  and  a  case  has  been  reported  where  pregnancy 
began  in  the  eighth  year  and  was  followed  by  childbirth  in  the  ninth. 
On  the  other  hand,  childbirth  has  been  observed  at  the  age  of  sixty- 
two  years. 


CHAPTER    III. 

OVULATION   AND    THE   OVUM. 

Embryology  teaches  us  that  at  the  earliest  stage  the  ovary  is  repre- 
sented by  a  heap  of  cells,  the  germ  epUhelium,  rising  from  that  portion 
of  the  peritoneum  which  covers  the  Wolffian  body,  and  that  soon  a 
protuberance  of  connective  tissue  grows  from  behind  into  this  nms& 
of  cells.  These  two  elements  build  up  the  whole  ovary,  the  cells  pro- 
ducing the  parenchyma,  or  glandular  element,  and  the  connective 
tissue  furnishing  the  stroma  in  which  the  former  is  embedded.  Pro- 
longations of  connective  tissue  grow  in  between  the  cells,  so  as  to 
separate  them  into  groups  and  form  a  roof  over  them  ;  but  from  this 
layer  sprout  new  prolongations,  while  new  cells  are  constantly  formed 
on  the  surface.     In  this  way  are  formed  irregular  tubes  which  inter- 


OVULATION    AND    THE    OVUM. 


communicate,   much  like  the  canals  in  a  sponge  (Figs.   1,  2,  3,  4). 
Finally,  the  whole  surface  is  covered  only  with  a  single  layer  of  cells, 


W 


,<^T^^ 


Ovary  of  human  fcEtus  of  ten  or  eleven  weeks.  ( H.  Meyer.)  a,  superficial  stratum  of  cells ; 
6,  layer  of  connective  tissue  ;  c,  trabeculae  of  connective  tissue,  the  cells  having  been  removed  ; 
d,  mesoarium  ;  e,  part  near  surface,  seen  with  higher  power  ;  n,  natural  size  of  the  whole  specimen. 

the  columnar  epithelium  of  the  ovary,  under  which  is  found  a  layer  of 
connective  tissue,  the  future  cdbuginea^  and  under  that,  again,  clusters 

Fig.  2. 


/    \ 


Part  of  ovary  near  surface,  from  human  foetus  of  sixteen  weeks,  showing  formation  and  separation 

of  ova.     (H.  Meyer.) 

of  cells  surrounded  by  connective  tissue  (Fig.  5),  or  sometimes  a  long 
row  of  large  cells,  each  surrounded  by  smaller  cells,  until  all  these 

Fig.  3. 


Part  of  ovary  near  surface,  from  human  foetus  of  twenty-eight  weeks.    In  some  places  appears  the 
permanent  epithelium,  composed  of  a  single  layer.     (H.  Meyer.) 

columns  and  clusters  are  broken  up  into  small  compartments,  each 
containing  one  large  cell  and  one  or  more  smaller  ones  (Fig.  G). 


4  OBSTETRICS— FOUNDATION. 

The  large  cells  have  each  a  nucleus  and  a  nucleolus  and  are  the 
future  ova.     They  are  called  primordial  ova.    According  to  Waldeyer, 


Fig.  4. 


: "  v^ 


Part  of  ovary  near  surface,  from  human  fcetus  of  thirty-six  weeks.    The  single  layer  of  epithelium 
is  interrupted  by  a  belated  primordial  ovum  with  its  follicular  epithelial  cells.     (H.  Meyer.) 


Fig.  5. 


CJ^ 


,-:^^^^^, 


if,     Qli'^,\ 


i^i 


'W-'- 


Part  of  section  from  surface  to  hilum  of  ovary  of  girl  three  days  old.  (H.  Me>er-i  '^  single 
layer  of  epithelium,  still  in  connection  with  cluster  of  primordial  ova.  All  ova  have  disappeared 
from  the  surface.  A  broad  layer  of  stroma  separates  in  most  places  the  epithelium  from  the  follicu- 
lar zone.  The  farther  we  go  from  the  surface  the  fewer  ova  are  there  in  one  nest,  until,  finally,  there 
is  only  one  enclosed  in  its  primary  follicle,    n,  natural  size  of  the  whole  ovary. 


Fig.  6. 

6 


.d 


Perpendicular  section  through  the  ovary  of  a  bitch  of  six  months.  Hartnack  f .  (Waldeyer.) 
a,  epithelium ;  6,  epithelial  pouch  opening  on  the  surface ;  c,  larger  group  of  follicles  ;  d,  tube  filled 
with  ova,  each  surrounded  by  smaller  cells ;  c,  oblique  and  transverse  sections  of  tubes.  It  is  notice- 
able that  some  of  the  cells  are  large,  others  small. 

the  small  cells  multiply  and  form  the  epithelial  lining  of  the  primary 
folUdes  (Fig.  7),  which  are  the  rudimentary  Graafian  follicles.    Accord- 


OVULATION   AND    THE    OVUM.  5 

ing  to  Foulis,  however,  these  epithelial  cehs  of  the  folhcles  are  due  to 
a  transformation  of  the  surrounding  connective  tissue. 


Fig.  7. 


Three  Graafian  follicles  from  the  ovary  of  a  new-born  child.  Enlarged  three  hundred  and  fifty 
times.  (Kolliker.)  ],  natural  condition;  2,  treated  with  acetic  acid;  o,  structureless  membrane; 
6,  epithelium  (membrana  granulosa) ;  c,  yolk  ;  d,  germinal  vesicle  with  germinal  spot ;  e,  nuclei  of 
the  epithelial  cells  ;  /,  vitelline  membrane. 

The  small  cells  increase  in  number  and  form  several  layers.     A 
fissure    is    formed   between  them,   and  a  fluid  accumulates  in    the 


Fig.  8. 


Graafian  follicle  from  a  girl  seven  months  old.  Enlarged  two  hundred  and  twenty  times ; 
natural  size,  0.351  millimetre  in  the  longest  diameter.  (Kolliker.)  a,  epithelium  (membrana 
granulosa),  detached  from  fibrous  membrane  ;  b,  discus  proligerus,  situated  far  away  from  the  sur- 
face. It  contains  the  ovum,  ur>on  which  the  zona  pellucida  and  the  germinal  vesicle  are  visible. 
The  surrounding  fibrous  membrane  is  not  yet  separated  into  two  layers,  and  there  is  no  distinct 
line  of  demarcation  between  it  and  the  surrounding  tissue. 

interior,  the  beginning  of  the  future  liquor  follieuli.    The  outer  layers 
constitute  the  epithelium  of  the  Graafian  follicle,  the  so-called  mem- 


6 


OBSTETRICS— FOL'XDATIOX. 


braiia  granulosa;  the  inner  continue  to  surround  the  ovum,  forming 
a  protuberance  on  the  inner  surface  of  the  folhcle,  called  the  diseus 
proligerus  (Fig.  8). 

The  formation  of  ova  from  the  surface  epithehum  of  the  ovary 


Primordial  ova  undergoing  division,  from  a  human  embryo  of  six  months.  Enlarged  four  hun- 
dred times.  (KolUker. )  1,  primordial  ovum  with  two  nuclei  (germinal  vesicles)  ;  2,  two  primordial 
ova,  linked  together  hy  a  band  of  protoplasm,  the  whole  surface  being  surrounded  by  a  single 
layer  of  epithelium  ;  3.  two  primordial  ova.  surrounded  by  a  common  layer  of  epithelium ;  one  ovum 
has  a  prolongation  by  means  of  which  it  probably  was  attached  to  another  ovum. 

ceases  from  the  time  the  single  layer  of  cells  is  formed,  which  takes 
place  about  the  end  of  tlie  seventh  month ;  but  it  seems  tliat  the  ova 
themselves  multiply  by  division  (Fig.  9). 

The  number  of  ova  in  the  new-born  is  enormous.     It  has  even 
been-  computed  to  be  seventy-two  thousand  in  the  two  ovaries,  a 


Fig.  10. 


V 


zo 


1  -~o 


Ovar^-  and  tube  of  a  nineteen-vear-old  girl.    (Waldeyer.)    T,  uterus ;  T,  tube  :  iO,  ovarian  ligament 
(unusually  long) ;  o,  ovary  ;  x,  limit  of  peritoneum. 

superabundant  provision,  indeed,  for  the  preservation  of  the  human 
race  on  earth,  when  we  take  into  consideration  the  fact  that  probably 
only  one  or  two  ova  are  loosened  once  a  month  during  a  period  of 
thirty  years. 


OVULATION   AND    THE   OVUM.  7 

In  mammalia-  the  process  of  ovulation — that  is,  the  expulsion  of 
ova — is  perfectly  known.  Before  each  recurrence  of  rut  one  or 
more  Graafian  follicles  ripen  and  burst.  The  ovum  is  expelled  and 
enters  the  Fallopian  tube,  through  which  it  is  propelled  by  the  move- 
ment of  the  cilia  of  the  epithelium  into  the  uterus.  If  copulation 
takes  place,  the  ovum  meets  a  spermatozoid  and  is  nearly  always 
fertilized.  In  the  ovaries  are  found  a  number  of  corpora  lutea  cor- 
responding to  that  of  the  foetuses. 

In  woman  the  anatomical  construction  of  the  ovaries  is  much  like 
that  of  the  ovaries  of  mammals.  They  are  covered  with  a  single  layer 
of  hexagonal  columnar  cells,  forming  their  epithelium.  In  the  young 
girl  the  ovary  is  smooth  and  soft  (Fig.  10).  Later,  each  ovulation 
leaving  a  small  cicatrix,  the  surface  becomes  a  little  puckered  (Fig.  11), 

Fig.  11. 

T 


Ovary  and  tube  of  a  girl  tweuty-four  years  old.    (Waldeyer.)     f7,  uterus;  T,  tube;  LO,  ovarian 
ligament ;  o,  ovary  ;  x,  limit  of  peritoneum ;  6,  cicatrices  of  ruptured  Graafian  follicles. 

and  in  old  age  it  becomes  uneven,  hard,  nearly  cartilaginous,  and  in 
places  the  epithelium  is  lost. 

Even  macroscopically  the  ovarium  shows  on  its  cut  surface  two 
different  component  parts, — an  outer,  called  the  parenchymatous  zone 
or  cortical  substance,  and  an  inner,  called  the  vascular  zone  or  medullary 
substance.  Under  the  microscope  more  layers  appear.  Under  the 
epithelium  hes  the  albuginea,  in  which  three  layers  are  distinguishable, 
forming  a  resist  nt  fibrous  membrane  with  interspersed  smooth 
muscle-fibres.  Under  the  albuginea  is  found  a  zone  containing  numer- 
ous small  follicles,  called  ovisacs  or  primary  Graafian  follicles.  Inside 
of  this  zone  is  found  another,  with  much  larger  follicles  in  different 
stages  of  development.  The  tissue  in  which  these  follicles,  small 
and  large,  are  embedded  consists  chiefly  of  smooth  nmscle-fibres  and 
connective  tissue,  arranged  so  as  to  form  circles  around  each  follicle. 


8  OBSTETRICS— FOUNDATION. 

The  medullary  zone  is   composed   of  similar  elements,  but  is  much 
softer  and  contains  large  blood-vessels.     The  largest  vessels  are  found 

Fig.  12. 


Section  of  the  ovary  of  a  cat.  Enlarged  six  times.  (Schron.)  1,  outer  covering  (epithelium 
and  albuginea)  ;  1',  attachment  to  broad  ligament;  2,  vascular  zone  or  medullary  substance;  3, 
parenchjTnatous  zone  or  cortical  substance  ;  4,  blood-vessels  ;  5,  Graafian  follicles  in  their  primary 
stage,  lying  near  the  surface  ;  6,  7,  8,  more  advanced  follicles,  embedded  more  deeply  in  the  stroma ; 
9,  an  almost  mature  follicle,  containing  the  ovum  in  its  deepest  part,  most  remote  from  the  surface ; 
y,  a  follicle  from  which  the  ovum  has  accidentally  disappeared  ;  10,  corpus  luteum. 

Fig.  13. 


,  ^^/'^ 


Part  of  the  same  section  of  the  ovary  of  a  cat  seen  m  Fig  1''  Enlarged  about  twenty  four  times. 
(Schron.)  1,  the  epithelium  and  albuginea  ;  2,  fibrous  and  muscular  stroma  ;  3,  less  fibrous,  more 
superficial  stroma  ;  4,  blood-vessels  ;  5,  small  Graafian  follicles,  situated  near  the  surface  ;  6,  a  few 
more  deeply  placed  ;  7,  one  further  developed,  showing  the  internal  epithelium  of  the  Graafian 
follicle,  the  discus  proligerus,  the  ovum,  with  the  germinal  vesicle  and  germinal  spot,  and  the 
fissure  between  the  epithelium  of  the  ovum  and  that  of  the  follicle  ;  the  follicle  is  surrounded  by 
stroma  arranged  in  a  circle  and  communicating  with  that  of  the  vascular  zone  ;  8,  a  more  advanced 
stage,  the  membrana  granulosa  showing  several  layers  ;  9,  part  of  the  largest  follicle  ;  o,  membrana 
granulosa ;  6,  discus  proligerus ;  c,  ovum  ;  d,  germinal  vesicle ;  e,  germinal  spot. 

near  the  hilum ;  towards  the  surface  they  are  smaller  and  surround 
each  follicle  with  a  fine  capillary  net-work  (Figs.  12,  13,  14,  15). 


OVULATION   AND   THE    OVUM. 


9 


The  small  follicles,  measuring  from  0.02  to  0.08  millimetre,  are 
the  same  primary  follicles  found  in  the  developmental  age,  but  of 
the    enormous  number   comparatively    few  are    left.      This  gradual 


Fig.  14. 


Longitudinal  section  through  ovary  of  a  woman  twenty-two  days  after  the  last  menstruation. 
(Leopold.)  m.f..  mature  Graafian  follicle  ;  pr.,  most  prominent  point  of  follicle,  where  the  rupture 
may  be  expected. 


Fig.  15. 


diminution  of  ovisacs  appears  distinctly  in  the  three  cuts  represented 
in  Fig.  16,  which  gives  a  comparative  view  of  the  ovaries  of  a  new- 
bom  child,  a  girl  four  years  old,  and  a  woman  of  twenty.  The  large 
follicles  are  more  properly  called  Graafian  follicles,  and  can  be  seen 
with  the  naked  eye  as  vesicles  of  the  size  of  peas  (Figs,  14,  15). 
There  are  from  six  to  twenty  of  them  in  each 
ovary.  The  follicles  do  not  change  place.  It 
is  only  by  their  growth  that  they  push  the 
surrounding  tissue  aside  and  sink  down  into 
the  deeper  parts  of  the  ovary,  at  the  same 
time  that  they  approach  the  surface.  They 
may  attain  the  size  of  a  large  hickory-nut  or 
a  small  English  walnut.  Finally,  on  the  most 
prominent  point  all  the  tissue  between  the  fol- 
licle and  the  surface  of  the  ovary  atrophies, 
and  a  slight  force,  be  it  a  contraction  of  the 
muscular  tissue  encircling  the  follicle  or  an 
increased  rush  of  blood  to  the  ovary,  suffices 

to  cause  the  rupture  of  the  follicle.  At  the  same  time  the  liquor  fol- 
liculi  escapes,  carrying  with  it  the  ovum,  still  surrounded  by  some 
of  the  cells  of  the  discus  proligerus. 


Longitudinal  section  of 
ovary  of  a  woman  on  the  first 
day  of  menstruation,  with  one 
burst  follicle  opening  on  the 
surface  and  other  follicles  in 
different  stages  of  develop- 
ment.    (Leopold.) 


10 


OBSTETRICS— FOUNDATION. 


The  wall  of  the  fully  developed  Graafian  folhcle  consists  of  two 
layers,  called  theea  externa  and  theca  interna^  and  inside  of  the  latter 


Fig.  16. 
B 


Mj       ^-^M^MM 


i-mM^MkM& 


[J        r  ~\ 


3 -''L     ^i 

:0 


\^ 


Perpendicular  section  of  the  cortical  substance  of  the  ovary  :  A,  in  the  new-born  ;  fi,  in  a  girl 
four  years  old  ;  C,  in  a  woman  of  twenty.  (Sappey. )  1,  columnar  epithelium ;  2,  cortical  substance ; 
3,  medullary  substance ;  4,  more  developed  ovisacs,  with  distinct  ova. 

Fig.  17. 


L.c.  . 


Part  of  wall  of  young  Graafian  follicle  of  a  pig.  Enlarged  two  hundred  times.  (J.  G.  Chirk.) 
The  first  change  from  ordinary  connective  tissue  to  lutein-cells  is  seen.  The  membrana  propria 
forms  a  sharp  dividing  line  between  the  epithelial  cells  (membrana  granulosa)  and  the  follicle 
wall.  Ep.,  epithelium;  M.p.,  membrana  propria;  Th.L,  theca  interna;  C.t.c,  connective-tissue 
cells;  i.e.,  lutein-cells. 

there  is  a  structureless  membrane   called  membrana  j)ropria,  which 
appears  before  the  two  other  layers  have  been  formed  (Fig.  1 7). 


OVULATIOx^   AND    THE   OVUM. 


11 


After  being  ruptured  the  follicle  collapses,  or  is  sometimes  filled 
with  blood  that  coagulates.  The  structureless  membrane  breaks  in 
several  places,  and  the  cavity  is  invaded  by  the  so-called  lutein-ceUs, 
which  are  transformed  connective-tissue  cells,  first  appearing  in  the 
theca  interna  (Fig,  18).  A  fine  net- work  of  connective  tissue  fills 
the  cavity  of  the  follicle,  which  becomes  nearly  as  large  as  before  its 
rupture,  but  this  period  of  increase  does  not  extend  beyond  ten  days. 
Near  the  wall  the  cells  lie  in  folds,  but  they  soon  undergo  fatty  degen- 
eration and  the  connective  tissue  shrinks.  The  fatty  degeneration 
gives  rise  to  a  yellow  color,  which  has  caused  the  follicle  at  this  stage 
to  be  called  a  corpus  luteum, — i.e.,  yellow  body  (Fig.  19). 

Gradually  the  fibrous  tissue  is  absorbed  through  hyaline  degener- 
ation, until  a  very  fine  scar-tissue  is  left,  which  at .  last  is  lost  in  the 
ovarian  stroma.  At  the  end  of  eleven  weeks  its  volume  measures 
only  one-twentieth  of  a  cubic  centimetre.     As  a  rule,  we  find  in  an 

Fig.  18. 


Fig.  19. 


M.p.        Th.i.  V.  Th.e.  Ep. 

Follicle  in  about  the  middle  stage  of  growth.  (J.  G. 
Clark.)  Ep.,  epithelium;  M.p.,  membrana  propria; 
Th.i.,  theca  interna  with  well-differentiated  lutein- 
cells;    Th.e.,  theca  externa;   T'.,  blood-vessel. 


Ovary  of  woman,  with  coipus 
luteum  and  Graafian  follicles,  fifteen 
days  after  the  last  menstruation. 
(Leopold.) 


ovary  three  or  more  such  corpora  lutea  in  different  stages  of  growth 
or  retrogression.  Each  such  process  leads,  however,  to  some  harden- 
ing of  the  ovarian  tissue,  until  in  the  course  of  time  the  outer  parts 
of  the  stroma  become  so  dense  that  circulation  stops  in  the  periphery 
and  thus  an  end  is  put  to  the  development  of  new  follicles. 

If  pregnancy  occurs,  no  new  corpora  lutea  are  produced,  but  the 
last  one  formed  becomes  larger  and  remains  longer  visible.  It  con- 
tinues to  grow  for  thirty  or  forty  days  and  occupies  two-thirds  of  the 
ovary,  being  about  three  centimetres  in  length.  In  the  centre  of  the 
yellow  convolutions  is  found  a  firm,  fibrinous,  white  mass,  which  some- 
times has  a  central  cavity  filled  with  a  serous  fluid.  Beyond  a  certain 
period  of  pregnancy  (about  the  end  of  the  third  month),  the  corpus 
luteum  diminishes  in  size  and  loses  some  of  its  bright-yellow  color. 
It  is  still  found  at  the  end  of  pregnancy,  but  is  then  reduced  in  volume 


12 


OBSTETRICS— FOUNDATION. 


to  half  a  cubic  centimetre.  Finally,  it  disappears  at  the  end  of  the 
first  month  after  childbirth.  The  difference  as  to  size,  construction, 
and  persistence  between  the  corpus  luteum  of  pregnancy  and  that  of 
menstruation  must  be  borne  in  mind  in  deciding  whether  a  woman 
upon  whom  a  legal  autopsy  is  being  performed  was  or  had  recently 
been  pregnant  or  not. 

We  do  not  know  with  certainty  if  the  expulsion  of  an  ovum  is 
connected  with  menstruation  in  women  as  it  is  with  the  rut  in 
animals  ;  but  it  is  very  likely  that  a  follicle  ruptures  immediately  be- 
fore the  menstrual  flow  commences. 

Fig.  20. 


Human  ovum  removed  from  the  discus  proligerus  of  a  Graafian  follicle  eight  millimetres  in 
diameter.  (Nagel.)  6.,  germinal  vesicle  with  double  germinal  spot ;  T'.,  vitellus;  Z.p.,  zona  pellu- 
cida;  C.,  corona;  Z.g.,  zona  granulosa  (part  of  discus  proligerus,  which,  again,  is  a  part  of  the 
membrana  granulosa,  forming  the  epithelium  of  the  follicle). 


The  expelled  ovum  falls  into  the  abdominal  cavity,  and  reaches 
the  abdominal  ostium  of  the  tube  through  the  current  produced  by 
the  vibration  of  the  cilia  on  the  fimbriee  of  the  Fallopian  tube,  which 
mechanism  has  been  proved  experimentally  by  injecting  the  eggs  of 
ascarids  into  the  upper  part  of  the  abdominal  cavity  of  a  rabbit.  In 
ten  hours  they  were  found  in  the  tubes. 

We  know  also,  from  experiments  on  animals  and  pathological 
conditions  in  women,  that  an  ovum  can  wander  from  the  ovary  on 
one  side  to  the  tube  on  the  other, — so-called  external  migration  of  the 
ovum.     In  opposition  to  this,  internal  migration  of  the  ovum  means  the 


MENSTRUATION.  13 

passage  of  the  ovum  from  one  ovary  through  the  tube  and  uterine 
cavity  into  the  opposite  tube.  It  is  uncertain  whether  such  a  thing  is 
possible  in  woman ;  and  even  in  animals  it  has  only  been  proved  by 
observation  and  experiment  that  an  ovum  can  migrate  from  one  horn 
of  a  bicornute  uterus  to  the  other. 

The  human  ovum  (Fig.  20)  is  a  little  globular  body,  averaging  0.2 
millimetre  in  diameter,  and  just  visible  with  the  naked  eye.  The 
nearest  cells  of  the  discus  proligerus  form  around  it  a  regular  double 
layer  of  elongated  cells,  the  so-called  corona.  The  ovum  has  a  mem- 
brane with  radiating  stride,  called  zona  pelluoida  or  vitelline  membrane. 
The  interior  is  filled  with  a  semifluid  mass,  the  vitellus.  This  is  com- 
posed of  larger  clear  bodies,  minute  dark  ones,  and  one  much  larger 
vesicle,  the  germinal  vesicle,,  in  which  is  found  a  little  round  body,  the 
germinal  spot.  The  last-named  contains  a  few  dark  granules,  and 
sometimes  similar  bodies  are  found  in  the  germinal  vesicle  outside  of 
the  germinal  spot.  The  whole  ovum  is  a  cell,  the  zona  pellucida  its 
membrane,  the  vitellus  its  contents,  the  germinal  vesicle  its  nucleus, 
and  the  germinal  spot  its  nucleolus. 


CHAPTER    IV. 
MENSTRUATION. 


Menstruation  is  the  discharge  of  blood  from  the  cavity  of  the 
uterus,  recurring  at  regular  intervals.  It  is  also  called  the  me7ises,  the 
catamenia,  the  menstrual  period.,  the  monthly  sickness,  the  monthly  Jioiv, 
courses,  or  turns. 

This  phenomenon  is  peculiar  to  woman  and  some  species  of  apes. 
It  is  probably  due  to  the  erect  position  usually  maintained  by  mankind 
and  these  animals,  which  necessitates  a  harder  consistency  of  the 
womb  and  excludes  the  presence  of  the  enormously  developed 
lymphatic  system  which  is  found  in  the  flabby  uteri  of  animals  walk- 
ing on  four  feet. 

The  menstrual  flow  commences  in  most  women  in  the  temperate 
zone  between  the  fifteenth  and  seventeenth  years  of  their  lives.  It 
begins  earlier  in  warm  climates  than  in  cold,  earlier  in  cities  than  in 
the  country,  and  earlier  in  the  higher  walks  of  society  than  among 
the  lower  classes.  It  returns  in  periods  of  twenty-eight  days,  and 
lasts  on  an  average  four  days.  The  amount  of  blood  evacuated 
varies  much,  but  four  or  five  ounces  are  said  to  be  the  average.  It  is 
increased  by  bodily  exercise,  corporeal  work,  and  the  internal  use  of 
alcohol  and  iron.  The  menstrual  blood  diff'ers  from  that  from  other 
sources  by  a  more  or  less  considerable  admixture  of  epithelial  cells 
and  mucus  and  by  a  peculiar   "heavy"   odor.      It  is  secreted   by 


14 


OBSTETRICS— FOU^'DATION. 


the  mucous  membrane  of  the  uterus  and  probably  the  tubes,  while 
the  cervix  has  no  part  in  its  production.  Before  the  appearance  of 
the  flow  the  woman  has  a  sensation  of  heaviness  or  pressure  in  the 
lumbar  region,  and  often  her  breath  has  an  unpleasant  and  character- 
istic odor  during  the  period. 

If  menstruation  has  been  evolved  from  the  rut  in  mammalia,  it  has 
changed  much  in  character.  While  female  anunals  admit  the  male 
only  during  the  period  of  heat,  woman  not  only  lias  an  aversion  for 
sexual  intercourse  during  menstruation,  but  the  act  performed  during 

Fig.  21. 


rterus  during  menstruation.  (Courty.)  Cut  open  to  show  the  swelling  of  the  whole  organ, 
I)articularly  the  mucous  membrane.  A,  mucous  membrane  of  the  cervis  ;  B  and  C,  mucous  mem- 
brane of  the  corpus,  much  thickened ;  Z),  muscular  layer ;  E,  uterine  opening  of  the  Fallopian 
tube ;  F,  os  internum. 

the  catamenial  period  exposes  both  sexes  to  disease.  As  a  rule, 
menstruation  ceases  during  pregnancy  and  lactation,  but  exceptions 
to  these  rules,  especially  the  latter,  are  by  no  means  rare. 

The  anatomical  base  of  menstruation  is  a  regularly  recurrent 
development  of  the  endometrium  (Fig.  21).  About  a  week  before 
the  menstrual  flow  sets  in,  the  mucous  membrane  of  the  uterus  be- 
gins to  swell,  so  that  its  thickness  increases  from  one-eighth  of  an 
inch  to  one-quarter  of  an  inch  in  the  middle  of  the  side  walls  and 
the  fundus,  from  which  points  it  tapers  towards  the  three  openings 
leading  to  the  tubes  and  the  cervix.  In  consequence  of  the  dispro- 
portion between  it  and  the  surrounding  muscular  coat,  its  surface 


MENSTRUATION.  15 

becomes  wavy.  The  arteries  become  much  enlarged  and  form  spiral 
windings.  Under  the  epithelium  the  capillaries  become  so  much  en- 
larged that  they  form  a  plexus  discernible  with  the  naked  eye.  On 
the  other  hand,  the  mucous  membrane  contains  only  few  and  small 
veins.  The  utricular  glands  become  much  wider  and  longer,  forming 
spiral  or  zigzag  tubes.  The  interglandular  connective  tissue  is  filled 
with  numberless  small  round  cells,  like  lympli-coriDUScles,  and  giant 
cells  containing  many  nuclei  (Fig.  22).  These  corpuscular  elements 
are  found  in  much  smaller  number  during  the  intermenstrual  period, 

Fig.  22. 


Section  of  the  endometrium  of  a  menstruating  woman,  shomng  Ij-mph-corpuseles  and  utricu- 
lar glands  denuded  of  or  shedding  their  epithelium.  Enlarged  eight  hundred  times.  (A.  W. 
Johnstone. ) 

and  are  formed  from  granules  in  the  threads  of  connective  tissue 
making  up  the  bulk  of  the  mucous  membrane  or  by  scission  of  one 
cell  into  two  (Fig.  23). 

Before  the  menstrual  period  the  blood-pressure  in  the  arteries  of 
the  whole  body  is  increased.  Microscopists  do  not  yet  agree  on  the 
question  whether  an  actual  rupture  of  the  blood-vessels  and  the 
epithelium  takes  place,  or  the  blood  oozes  out  through  the  intact  wall 
of  the  capillaries  and  the  epithelium  by  diapedesis ;  but  the  former 
seems  much  more  likely,  even  after  it  has  been  proved  that  the  whole 
epithelium  is  not  thrown  off,  as  was  formerly  taught.  There  are 
extravasations  into  the  tissue  of  the  mucous  membrane,  which  in 
some  places  lift  the  epithelium  and  cause  it  to  rupture,  giving  escape 


16 


OBSTETRICS— FOUNDATION. 


to  the  blood.  The  utricular  glands  shed  the  epithelium  in  the  portion 
situated  nearest  to  the  free  surface.  The  flow  lasts  four  or  five  days, 
and  then  the  work  of  repair  and  retrogression  begins,  which  takes 
only  about  four  days  for  its  accomplishment,  so  that  the  whole  pro- 
cess from  beginning  to  end  requires  about  fifteen  days,  or  fully  one- 
half  of  the  time  elapsing  between  the  beginning  of  one  menstruation 
and  the  commencement  of  the  next.  The  swelling  subsides ;  the 
utricular  glands  become  shorter,  narrower,  and  straighter,  and  are  again 
covered  with   epithelium   in    their   full    extent.       The    capillary  net 

Fig.  23. 


Fibre  of  endometrium,  showing  different  degrees  of  development  from  granules  to  cells. 
Enlarged  three  thousand  times.    (Johnstone.) 


shrinks,  the  small  wounds  heal,  and  most  of  the  lymph-like  bodies 
disappear. 

The  mucous  membrane  of  the  tubes  participates  in  the  process  of 
menstruation.  It  swells  and  secretes  a  thin  bloody  fluid  containing 
blood-corpuscles  and  epithelial  cells. 

As  stated  above,  authors  differ  in  regard  to  the  connection  be- 
tween menstruation  and  ovulation ;  but  even  if  the  exact  moment  of 
the  expulsion  of  the  ovum  in  woman  is  unknown,  and  it  is  not  proved 
whether  it  precedes,  accompanies,  or  follows  menstruation,  numerous 
autopsies  and  laparotomies  have  shown  that  there  is  a  correspondence 


MENSTRUATION.  17 

between  the  time  elapsed  since  tlie  beginning  of  the  last  menstruation 
and  the  degree  of  development  of  the  largest  corpus  luteum.  That 
there  is  some  connection  between  menstruation  and  ovulation  is  also 
corroborated  by  the  clinical  fact  that  abortive  ova  have  never  been 
found  corresponding  in  development  to  the  period  between  the  last 
menstruation  and  the  day  the  next  was  due. 

The  cause  of  menstruation  is  still  unknown.  Since  it  returns  in 
regular  intervals,  there  can  hardly  be  any  doubt  that  it  is  regulated 
by  some  centre  in  the  central  nervous  organs.  We  may  surmise  that 
the  growth  of  the  Graafian  follicle  exercises  a  pressure  on  the  ends 
of  the  ovarian  nerves  which  is  transmitted  to  that  centre,  and  that 
this  sends  out  an  impulse  resulting  in  the  development  of  the  uterine 
mucous  membrane  and  the  rupture  of  vessels.  It  is  probably  the 
same  increased  blood-pressure  that  causes  the  rupture  of  a  ripe 
Graafian  follicle  in  the  ovary  and  of  the  capillaries  in  the  mucous 
membrane  of  the  uterus. 

In  some  of  his  patients  the  writer  has  noticed  a  regular  alternation 
between  the  two  ovaries,  one  becoming  swollen  at  the  time  of  men- 
struation and  the  next  month  the  other,  and  so  forth ;  but  it  is  not 
known  if  such  a  regular  alternation  is  found  in  healthy  women.  The 
fact  is,  however,  that  Ave,  as  a  rule,  find  only  one  fully  developed  or 
ruptured  follicle  corresponding  to  a  menstruation. 

The  supposition  that  the  impulse  to  menstruation  starts  from  the 
ovaries  is  corroborated  by  the  fact  that  when  we  tie  the  pedicle  of 
the  ovary  and  remove  it  the  patient  nearly  always  has  a  bloody  dis- 
charge from  the  uterus,  and  by  the  other  fact  that  in  the  vast  majority 
of  cases  the  removal  of  both  ovaries  leads  to  a  premature  menopause. 
According  to  A,  W,  Johnstone,  menstruation  is  a  physiological  necessity 
in  women  and  erect  animals,  because  there  are  not  lymphatic  vessels 
enough  to  carry  off  the  enormous  surplus  of  lymph-corpuscles  pro- 
duced during  the  preparation  of  the  womb  for  the  possible  event  of 
conception.  In  its  swollen  condition  the  mucous  membrane  of  the 
uterus  is  called  decidua  menstrualis,  in  contradistinction  from  decidua 
graviditatis^  the  same  membrane  during  pregnancy. 

Before  leaving  the  subject  of  menstruation,  we  shall  add  that  it  is 
not  found  invariably  :  women  enjoying  perfect  health  may  go  through 
life  without  menstruating,  and  they  may  even  give  birth  to  children. 
Childbirth  may  also  occur  years  after  the  monthly  flow  has  stopped, — 
the  so-called  menojmuse.  In  diseased  conditions  the  non-appearance 
of  the  menstrual  flow  is  quite  common, — so-called  amenorrhoca. 

Aveling  has  aptly  called  the  growth  of  the  menstrual  decidua 
nidcdion  and  its  retrogressive  stage  denidation^  a  nest  being  built  for 
the. reception  and  protection  of  the  fertilized  ovum,  and  destroyed  if 
none  appears. 

2 


OBSTETRICS— FOUNDATION. 


CHAPTER    V. 

COPULATION. 

Copulation  is  the  act  of  union  of  the  male  and  female  genitals. 
On  the  part  of  the  male  it  is  dependent  on  erection,  a  stiffening  of  the 
penis.  In  the  woman  also  an  erection  takes  place  under  normal  cir- 
cumstances, the  clitoris  becoming  enlarged  and  curved  against  the 
dorsum  penis,  the  vestibulo-vaginal  bulb  entering  into  a  state  of  tur- 
gescence,  and  the  inner  genitals  becoming  the  seat  of  a  stasis  of  blood 

Fig.  24. 


The  vessels  of  the  vagina  and  internal  genitals  m  their  relation  to  the  superficial  muscular 
structures.  (Rouget.)  The  specimen  is  seen  from  behind.  Vascular  system  :  P  r,  vaginal  plexus ; 
PC,  cervical  plexus;  PL',  uterine  plexus;  H,  helicine  arteries  of  the  fundus  uteri;  h,  helioine 
arteries  of  hilum  of  ovary.  Muscular  system  :  VP,  insertion  of  the  muscle-bundles  of  the  vagina 
on  the  pubes  ;  VS,  bundles  of  the  same  muscular  coat  coming  from  the  region  of  the  sacro-iliac 
articulation;  VS,  uterine  muscle-bundles  which  accompany  the  preceding  and  constitute  to  a  great 
extent  the  posterior  layer  of  the  broad  ligament ;  VR,  recto-uterine  or  sacro-uterine  ligament ; 
LI,  inguinal,  or  pubic,  round  ligament,  spreading  over  the  whole  anterior  surface  of  the  uterus ; 
a,  muscular  bundles  coming  from  the  ovarian  ligament  {LO),  spreading  and  interlacing  with  h, 
the  bundles  coming  from  the  superior,  or  lumbar,  round  ligament  (LS),  in  the  interior  of  the 
ovary,  and  beyond  in  the  ala  vespertilionis,  before  they  are  inserted  on  the  tube  and  the  fimbrise ; 
a',  bundles  starting  from  the  ovary,  which  together  with  others  coming  directly  from  the  superior 
round  ligament  form  the  fimbria  ovarica. 

in  consequence  of  the  intimate  connection  between  the  round  liga- 
ment and  the  platysma  of  the  broad  ligament  with  the  superior  or 
lumbar  round  ligament,  which  accompanies  and  envelops  the  ovarian 
vessels  (Fig.  24).  But,  whereas  erection  is  a  conditio  sine  qua  non  in 
man,  it  is  not  so  in  woman.  Copulation  may  take  place  even  while 
she  is  unconscious  and  entirely  relaxed. 


COPULATION.  19 

The  vagina  is  the  organ  destined  by  nature  to  receive  and  form  a 
"  sheath"  around  the  male  organ,  as  a  scabbard  encompasses  a  sword, 
the  Latin  word  having  this  meaning.  It  is  not  superfluous,  as  it  may 
seem  to  some,  to  dwell  on  this  point.  The  writer  has  repeatedly 
examined  women  who,  although  they  had  been  married  for  years  to 
apparently  strong  men,  presented  untorn,  sharply  resisting  hymens. 
Sometimes,  but  not  always,  this  condition  is  explained  by  an  abnormal 
laxity  of  the  urethra,  so  that  the  examining  fmger  of  the  gynaecologist 
and  the  male  organ  during  copulation  find  less  resistance  there  than 
at  the  entrance  of  the  vagina,  the  result  of  which  is  that  copulation 
takes  place  in  the  urethra  and  the  bladder  without  the  parties  knowing 
their  mistake. 

Fig.  26. 

Fig.  25. 


Hymen  with  linear  openiiiT.     CTardieu.)  Annular  hymen.     (Tardieu.) 

The  hymen  normally  has  different  shapes.  The  most  common, 
especially  in  childhood,  is  that  of  a  strip  of  mucous  membrane  bent 
so  as  to  form  two  lateral  halves,  touching  each  other  in  a  straight 
middle  line  (Fig.  25).  In  other  cases  it  forms  a  ring  with  a  round 
opening, — annular  hymen  (Fig.  26).  In  others,  again,  it  has  the  shape 
of  a  crescent  (Fig.  27).     Often  the  border  is  indented  (Fig.  28). 

The  hymeneal  opening  being  much  smaller  than  the  part  it  is 
destined  to  admit,  at  the  first  complete  copulation  the  hymen  is  torn 
in  one  or  more  places,  forming  two  or  more  flaps  (Fig.  29).  This 
laceration  is  accompanied  by  considerable  pain  and  some  loss  of 
blood,  which  may  acquire  the  character  of  a  hemorrhage  and  call 
for  surgical  interference.  In  order  to  facilitate  intromission  and  save 
the  virgin  unnecessary  pain,  it  is  well  to  lubricate  the  male  organ  with 
white  vaseline.  From  a  diagnostic  stand-point  it  should  be  remembered 
that  a  careless  gynaecological  examination  may  have  on  the  hymen  an 
effect  similar  to  that  of  copulation. 


20 


OBSTETRICS— FOLWDATIU-X. 


N^v, 


Crescent-shaped  hymen. 


Many  young  married  couples  do  themselves  a  great  deal  of  harm 
bv  over-indulgence  in  sexual  gratification.  Even  in  cases  where  there 
was  no  element  of  infection,  the  writer  has  seen  serious  inflammation 

of  the  vagina,  uterus,   tubes,    and 
Fig.  27.  ovaries  follow  such  foolish  conduct. 

For  the  pure  girl  the  approach  of 
man  is  pamful,  accompanied  by 
wounds,  and  the  emotional  shock  is 
enormous.  She  ought,  therefore, 
to  be  treated  with  the  greatest  care 
and  be  spared  all  brutality. 

The  proper  position  "for  man, 
different  from  that  of  most  anmials. 
during  the  act  of  copulation  is 
chest  to  chest,  with  bent  knees, 
the  male  covering  the  female.  If, 
however,  the  husband  is  of  unusual 
weight,  it  is  better  or  necessary  for 
him  to  occupy  the  lower  position. 
If  intercourse  takes  place  during 
advanced  pregnancy,  it  should  be  in  the  lateral  position,  chest  to  back, 
so  as  to  avoid  all  pressure  on  the  gravid  uterus. 

Friction  between  the  male  and  female  copulative  organs  causes 
a  voluptuous  sensation  which  normally  ends  in  orgasm,  the  acme  of 
nervous  excitement,  which  seems  to  be  weaker  in  woman  than  in 
nian.  and  is  totally  alDsent  in  many  women. 
who  nevertheless  may  conceive  and  bear  ^^^-  28. 

children.  The  orgasm  is  accompanied  by 
the  ejaculation  of  the  semen  in  man  and 
of  a  mucous  fluid  in  woman.  If  orgasm 
is  weaker  m  woman  than  in  man,  it  also 
weakens  her  much  less  than  him,  a  differ- 
ence that  is  easily  explained  by  the  differ- 
ent composition  of  the  two  fluids  ejected 
and  the  profound  shock  sustained  by  the 
central  nen^ous  system  in  the  male. 

It  is  not  quite  certain  whether  part  of 
the  semen  ejaculated  enters  the  womb 
directly  dm-mg  the  act  of  copulation.    The  indented  hymen, 

round  ligaments  are  so  disposed  that  they 

may  adapt  the  cervical  canal  to  the  meatus  urinarius  so  as  to  form 
a  prolongation  of  the  male  urethra,  and  several  observers  have  seen 
the  cervix  open  wide  during  orgasm  accidentally  brought  on  by  a 
gjnfecological  examination.     In  this  way  suction  might  be  exercised 


t 


FECUNDATION. 


21 


by  the  uterus  itself,  and  the  semen  would  be  drawn  into  its  interior, 
besides  being  injected  by  contraction  of  tlie  perineal  muscles  in  the 
male.  But  this  is  probably  quite  exceptional,  and  under  ordinary 
circumstances  the  spermatozoids  doubtless  enter  the  uterus  by  their 
own  movements,  which  are  very  lively  and  powerful  and  all  go  in 

•  Fig.  29. 


Ruptured  hymen. 

one  chief  direction,  as  if  seeking  a  predestined  goal.     They  consist 
in  wavy  lateral  flexions  and  extensions  of  the  tail. 

That  the  part  the  uterus  plays  in  conception  cannot  be  a  very 
active  or  essential  one  appears  from  the  well-authenticated  cases  in 
which  pregnancy  occurred  in  spite  of  the  nearly  total  occlusion  of  the 
vagina  due  to  the  presence  of  a  transverse  partition. 


CHAPTER    VI. 
FECUNDATION. 

Fecundation,  fertilization,  conception,  or  impregnation  consists  in 
the  union  of  the  two  generative  elements,  the  spermatozoid  and  the 
ovum,  by  which  in  the  latter  begins  the  formation  of  a  new  individual. 

The  spermatozoids  are  formed  by  scission  and  further  develop- 
ment of  the  epithelial  cells  of  the  seminal  canals  of  the  testicles,  each 


22 


OBSTETRICS— FOUNDATION. 


Fig.  30. 


H 


MA 


t~\\ 


cell  producing  a  whole  bundle  of  spermatozoids.  In  shape  they 
much  resemble  a  tadpole.  They  are  composed  of  an  oval,  somewhat 
pomted  head,  a  short  middle  piece,  and  a  long,  thin  tail,  with  a  still 
finer  end-piece  (Fig.  30).  The  total  length  is  about  0.04  millimetre, 
or  one-fifth  the  diameter  of  the  ovum.  Spermatozoids,  as  a  rule, 
appear  in  boys  at  the  age  of  fifteen  or  sixteen  years,  and  are  constantly 
reproduced.  While  woman's  fruitful  period  ceases  comparatively  soon, 
there  are  numerous  examples  of  men  being  capable  of  procreation 
when  between  seventy  and  eighty  years  old,  and  perhaps  the  faculty 
is  normally  preserved  till  the  end  of  life.  In  the  adult  one  or  two 
fluidrachms  of  semen  are  ejaculated,  each  drop  of 
which  contains  myriads  of  spermatozoids. 

Probably  the  two  elements,  as  a  rule,  meet  each 
other  in  the  Fallopian  tube,  although  the  well-authen- 
ticated cases  of  ovarian  pregnancy  prove  that  the 
human  ovum  may  be  fertilized  while  it  is  still  em- 
bedded in  the  ovary ;  and  in  mammalia  the  sperma- 
tozoids are  found  on  it  within  twenty-four  hours  after 
coition,  showing  how  rapidly  they  pass  through  the 
uterus  and  tube,  although  the  direction  in  which  the 
cilia  of  the  mucous  membrane  of  these  organs  move  is 
opposed  to  the  penetration  of  the  spermatozoids  and 
all  in  favor  of  the  transport  of  the  ovum  to  and 
through  the  uterus. 

We  know  that  a  single  coition  at  any  time  may 
result  in  the  impregnation  of  a  Avoman,  but  experience 
has  shown  that  the  likelihood  of  such  an  event  is 
much  greater  shortly  before  or  shortly  after  menstrua- 
tion than  midway  between  the  end  of  one  and  the 
beginning  of  the  next  period.  Of  the  two  terms  that 
preceding  the  menstrual  flow  seems,  again,  to  offer  the  best  chance 
for  impregnation.  In  the  young  embryo  the  development  takes  place 
with  such  rapidity  that  an  interval  of  three  weeks  makes  an  enormous 
difference  in  the  condition  of  the  organs.  In  this  way  it  was  found 
that  three-fourths  of  the  young  embryos  corresponded  to  the  first 
skipped  menstruation,  and  only  one-fourth  to  the  end  of  the  pre- 
ceding, but  the  whole  number  of  the  examined  ova  is  too  small  to 
exclude  the  possibility  of  accidentals. 

The  fact  that  a  woman  may  be  impregnated  at  any  time,  however, 
does  not  prove  that  an  ovum  is  detached  in  the  same  moment,  for 
both  ova  and  spermatozoids  may  be  preserved  for  some  time  in  fruit- 
ful condition  in  the  genital  canal.  The  human  ovum  has  been  found 
on  the  fourth  day  of  menstruation  in  the  uterine  part  of  the  tube, 
and  in  another  case  one  and  a  quarter  inches  above  the  internal  os. 


Human  sperma- 
tozoids. (Retzius.) 
A,  front  view  of  a 
spermatozoid ;  B, 
side  view  ;  h,  head  ; 
m,  middle  piece  ;  t, 
tail ;  e,  end  piece. 


FECUNDATION. 


23 


How  long  it  stays  in  the  uterus  and  preserves  its  capability  of  be- 
coming fecundated  is  unknown.  In  animals  the  ovum  loses  this 
faculty  when  it  has  left  the  upper  part  of  the  tube.     It  seems,  there- 


FiG.  31. 


Fig.  32. 


l«IIII^M^ll "J'- 

Fecundation  of  ovum  of  a  mouse 
g.v.,  germinal  vesicle ;  sp.,  head  of  sper- 
matozoid. 


Fig.  33. 


Ovum  with  the  female  if. p.)  and 
male  {m.p.)  pronuclei  more  developed 
and  nearer  to  each  other. 


m.p 


Separation  of  polar  body  {p.b. ) ;  /.p., 
female  pronucleus;  in.p.,  head  of  sper- 
matozoid. 


Fig.  34. 


Formation  of  chromatin  fibres  and  the 
centrosoma.    p.b.,  polar  body. 


Fig.  35. 


n.s.,  nucleus  of  segmentation. 


Karyokinesis  preparing  the  first  fission. 


fore,  very  improbable  that  in  woman  it  should  preserve  this  faculty 
for  weeks  after  it  has  left  the  ovary,  whereas  no  fact  is  known  that 
would  conflict  with  the  supposition  that  the  human  spermatozoids 


24  OBSTETRICS— FOUXDATIOX. 

keep  their  vitality  for  weeks  in  tlie  folds  of  the  ampulla,  and  such 
possibility  is  absolutely  proved  to  exist  in  animals. 

How  the  union  of  the  male  and  female  germs  takes  place  in 
^voman  is  not  known,  but  there  is  every  reason  to  believe  that  the 
process  is  essentially  the  same  as  that  observed  directly  with  the 
microscope  in  animals.  Figs.  31-38  illustrate  the  changes  in  the 
ovum  of  a  mouse  (Sobotta).  As  a  rule,  one  spermatozoid  suffices 
for  the  fecundation  of  the  ovum.  It  perforates  the  zona  pellucida  of 
the  ovum,  enters  the  vitellus,  and  throws  off  its  tail  (Fig.  31).  Ere 
this  a  karyokinetic  process  has  taken  place  in  the  germinal  vesicle, 
a  part  of  the  stainable  mass  having  arranged  itself  into  the  shape  of  a 
ball  of  cord,  forming  two  polar  bodies,  or  directing  globules,  or  extrusion 

Fig.  37.  Fig.  38. 


End  of  first  fission.  Two  blastomeres,  one  in  a  state  of  mitosis, 

preparing  for  second  segmentation. 

globules  (in  the  mouse  only  one),  and  being  pushed  towards  the  surface 
of  the  ovum.  That  portion  of  the  stainable  mass  which  is  not  used 
for  the  formation  of  the  polar  bodies  becomes  the  femcde pronucleus 
(Fig.  32),  while  the  head  of  the  spermatozoid  swells  and  becomes  the 
mcde  'pronucleus.  Both  these  pronuclei  increase  considerably  in  stain- 
able matter  and  approach  each  other  (Figs.  33,  34)  until  they  blend, 
forming  one  body,  the  nucleus  of  segmentation  (Fig.  35),  which  by 
mitosis  separates  into  two,  around  which  the  vitellus  forms  two  masses 
called  blastomeres,  the  direction  of  the  fission  being  determined  by  the 
position  of  the  directing  bodies.  In  the  same  way  each  of  the  two 
blastomeres  is  separated  by  mitosis  into  two  segments,  so  as  to  form 
four  in  all.  By  continued  division  the  number  is  repeatedly  doubled, 
and  the  globules  gradually  take  the  appearance  of  true  cells,  the 
whole  process  being  a  very  rapid  one.  In  rabbits  segmentation,  which 
is  the  technical  term  designating  the  breaking  up  of  the  vitellus  into 
parts  or  segments,  begins  two  hours  after  the  union  of  the  male  and 
the  female  pronucleus  and  is  accomplished  within  from  seventy  to 
seventy-five  hours,  by  which  time  the  ova  have  passed  through  the 
tube  and  entered  the  uterine  cavity. 


FECUNDATION. 


25 


First  stages  of  segmentation  of  the  ovum  of  a  rabbit.  (Allen  Thomson,  after  Edward  van 
Beneden's  description.)  zp,  zona  pellucida  ;  pgl,  polar  globules ;  ect,  ectomere ;  enl,  entomere; 
((,  di^^sio^  into  two  blastomeres  ;  6,  stage  of  four  blastomeres  ;  c,  eight  blastomeres,  the  ectomeres 
partially  enclosing  the  entomeres  ;  d  and  e,  succeeding  stages  of  segmentation,  showing  the  more 
rapid  division  of  the  ectomeres  and  the  enclosure  of  the  entomeres  by  them. 


Fig.  40. 


ent. 


Section  of  the  ovum  of  a  rabbit  during  the  later  stages  of  segmentation,  showing  the  formation 
of  the  blastodermic  vesicle.  (Edward  van  Beneden.)  a,  enclosure  of  entomeres  by  ectomeres, 
except  in  one  sjiot ;  h,  more  advanced  stage,  in  which  fluid  is  beginning  to  accumulate  between  the 
entomeres  and  ectomeres  ;  c,  fluid  has  increased  much,  a,  large  space  separating  them,  except  in  one 
place ;  d,  blastodermic  vesicle ;  zp,  zona  pellucida ;  ect,  ectodermic  cells ;  ent,  entodermic  cells. 


26  OBSTETRICS— FOUNDATION. 

From  the  very  beginning  a  difference  is  noticed  between  the  upper 
and  the  lower  segment,  the  former,  the  ectomere,  being  larger  than  the 
latter,  the  endomere  (Fig.  39).  When  the  third  stage,  where  there  are 
eight  spheroids,  is  reached,  the  lower  four  form  a  round  mass  and  the 
upper  show  a  tendency  to  surround  them.  A  difference  in  the  rate 
of  division  becomes  apparent,  the  upper  set  multiplying  faster  than 
the  lower.  At  the  same  time  the  upper  spheroids  show  more  and 
more  tendency  to  spread  over  the  lower  set,  until  finally,  in  the  tenth 
stage,  they  enclose  them  completely.  There  are  ninety-six  segments 
in  all,  of  which  sixty-four  are  those  of  the  surface,  the  ectoderm,  and 
thirty-two  those  of  the  interior,  the  entoderm  (Fig.  40).  The  whole 
mass  is  called  morula,  on  account  of  its  likeness  to  a  mulberry.  Next 
a  serous  fluid  begins  to  accumulate  between  the  endomeres  and  ecto- 
meres,  except  in  one  part,  where  they  remain  in  contact.  Thus  the 
ovum,  which  is  only  slightly  increased  in  size,  is  transformed  to  a 
vesicle,  to  which  at  a  later  period  the  name  blastodermie  vesicle  is  given. 


PART    II.— NORMAL    PREGNANCY. 


CHAPTER    I. 
TRANSPORTATION    AND   EMBEDDING   OF   THE    OVUM.       DECIDUA. 

The  fertilized  human  ovum  has  never  been  found  on  its  passage 
from  the  Graafian  follicle  to  the  uterus.  Nor  do  we  know  how  long 
the  transfer  takes.  The  youngest  fertilized  ova  known  must,  according 
to  their  degree  of  development  and  analogy  from  animals,  be  referred 
to  the  end  of  the  first  or  the  beginning  of  the  second  week  (ova  of 
Peters  and  Merttens).  One  supposed  to  be  twelve  or  thirteen  days 
old  (ovum  of  Reichert)  was  already  totally  embedded  in  the  mucous 
membrane  of  the  uterus. 

It  takes  the  fertilized  ovum  of  woman  probably  about  a  week  to 
cover  the  distance  from  the  ovary  to  the  uterus.  Its  presence  acts  as 
a  powerful  stimulus  on  the  latter,  especially  on  the  uterine  mucous 
membrane.  This  becomes  much  thicker,  even  half  an  inch  in  depth, 
and  is  called  the  decidua  of  pregnancy^  in  contradistinction  to  that  due  to 
a  similar  process  which  takes  place  on  a  smaller  scale  at  every  men- 
strual period  and  is  called  the  menstrual  decidua.  The  increase  in 
volume  is  due  to  the  enlargement  of  the  blood-vessels  and  the  utricu- 
lar glands.  A  perpendicular  section  of  the  decidua  of  pregnancy 
(Fig.  41)  shows  three  layers.  Near  the  surface  is  a  compact  layer ^  in 
which  the  glands  have  nearly  preser\^ed  the  course  they  follow  out- 
side of  pregnancy  and  in  Avhich  are  seen  greatly  enlarged  veins ;  out- 
side of  that  a  very  loose  layer  formed  chiefly  by  the  much  widened  and 
elongated  glands,  the  course  of  which  has  become  zigzag  and  irregular, 
— the  ampidlar  layer  ;  and,  finally,  a  somewhat  firmer  layer,  contain- 
ing the  deepest  parts  of  the  glands, — the  basic  layer. 

The  arteries  are  spiral-shaped.  The  surfaces  of  the  anterior  and 
the  posterior  wall  of  the  uterus  show  furrows  and  protuberances, 
which  give  it  a  puckered  appearance  (Fig.  42).  The  microscope 
reveals  the  presence  of  peculiar  large  cells  with  a  large  nucleus, — the 
so-called  decidual  cells. 

What  relations  are  there  between  the  menstrual  decidua  and  that 
of  pregnancy?  Since  we  cannot  kih  women,  as  we  do  rabbits,  at 
various  stages  after  impregnation,  this  will  probably  always  remain  a 
secret,  and  we  can  only  draw  on  our  imagination  and  reasoning  to  fill 
out  the  gaps  in  our  actual  knowledge.     When  we  take  into  consider- 

27 


28 


NORMAL   PREGNANCY. 


ation  the  great  likeness  between  the  two  deciduse, — one  bemg,  as  it 
were,  a  pocket  edition  and  the  other  an  edition  de  luxe  of  the  same 
^7ork, — it  seems  highly  probable  that  the  one  is  a  development  of  the 
other.  Remembering  the  clinical  fact  that  pregnancy  is  most  apt  to 
occur  shortly  before  menstruation,  we  can  imagine  that  the  fertilized 
ovum  is  deposited  on  the  well-prepared  mucous  membrane,  such  as 
it  is  before  every  menstruation,  and  that  then  the  process  takes  on 


Fig.  42. 


Fk;.  41. 


,,'  ccmyi. 


am/t 


Sas. 


muse. 


Perpendicular  section  through  the 
mucous  membrane  of  a  pregnant  uterus. 
(Langhans.)  muse,  muscular  coat ;  bas., 
the  basal  layer  of  the  decidua  ;  amp., 
the  ampullary  or  glandular  layer  of  the 
decidua;  comp.,  the  compact  layer  of 
the  decidua. 


Uterus  with  decidua  in  beginning  pregnancy. 
(Ruge.)  O.I.,  internal  os  ;  o.,  ovum,  covered  by  decidua 
reflexa ;  d,  decidua  vera. 


larger  proportions  until  the  decidua  of  pregnancy  is  formed.  Fur- 
thermore, inasmuch  as  the  next  best  period  for  fertile  copulation  is 
that  shortly  after  the  cessation  of  menstruation,  we  may  suppose  that 
the  condition  of  the  mucous  membrane,  although  less  favorable  than 
before  the  menstrual  flow  occurred,  in  its  swollen  and  succulent  con- 
dition still  offers  a  comparatively  good  soil  for  the  development  of  the 
fertilized  ovum.  If,  finally,  we  bear  in  mind  the  fact  that  midway  be- 
tween two  menstruations  is  the  time  in  which  pregnancy  is  least  likely 


DECIDUA. 


29 


to  occur,  it  is  probable  that  the  fertilized  ovum,  not  finding  a  propitious 
soil,  is  destroyed  and  lost.  In  those  cases  in  which  only  one  coition 
has  taken  place  and  pregnancy  has  developed,  although  the  event 
occurred  at  a  period  far  from  the  preceding  and  the  following  menstrua- 
tion, we  may  suppose  that  there  was  no  Graafian  follicle  ripe  at  the 
time  of  intercourse,  that  rupture  occurred  later,  and  that  the  sperm- 
atozoids  remained  alive  in  the  Fallopian  tube  until  an  ovum  came 
and  was  fecundated  by  the  union  with  one  of  them. 

However  this  may  be,  when  pregnancy  begins,  the  fertilized  ovum 
is,  as  a  rule,  arrested  near  the  internal  opening  of  one  of  the  Fallopian 
tubes,  tissue  grows  up  around  it  from  the  surface  of  the  mucous  mem- 
brane of  the  uterus,  and  soon  closes  over  it,  so  as  to  embed  it  entirely. 
In  the  youngest  human  ovum  known — that  of  Peters  (Fig.  43) — we 


Fig.  43. 


Human  ovum  from  end  of  first  week  of  pregnancy  embedded  in  the  decidua.  (Peters,  j  ut.ep., 
uterine  epithelium  ;  Embr.,  embryo  ;  sin.,  blood-spaces  between  the  villi  of  the  chorion  ;  ectod.,  ecto- 
derm ;  dec,  decidua;  anipa.,  ampullary  layer  of  decidua;  muse,  muscular  layer  of  uterus;  Thi;, 
thrombus,  composed  of  red  blood-corpuscles  and  ectoderm-cells;  v.ch.,  villi  of  the  chorion;  cap., 
capillary  ;  gl.,  gland  ;  mesod.,  mesoderm,  or  mesoblast. 

see  the  very  act  of  embedding,  the  ovum  being  flanked  by  glands  and 
resting  on  glands,  but  covered  only  by  uterine  epithelium,  in  which 
there  still  was  an  opening  communicating  with  the  uterine  cavity. 

When  the  ovum  grows,  this  part  of  the  decidua,  which  covers  it, 
forms  a  hood,  called  decidua  reflexa,  while  that  portion  of  the  decidua 
situated  between  the  uterus  and  the  ovum  is  named  decidua  serotina^ 
in  opposition  to  which  two  that  portion  which  lines  the  whole  uterine 
cavity  and  is  not  at  first  in  contact  with  the  ovum  is  called  decidua 


30 


xNORMAL   PREGNANCY. 


vera  (Fig.  44).  The  word  decidua  means  a  membrane  that  is  shed ; 
the  terms  reflexa  (bent  back)  and  serotina  (late  coming) _^date  from  a 
time  when  it  was  thought  that  the  ovum  carried  the  whole  mucous 
membrane  in  front  of  itself,  reflecting  it,  or  turning  it  back ;  and  that 
a  new  layer  of  decidua  was  formed  later,  which  closed  the  ovum  in 
from  behind.     Corresponding  to  our  present  knowledge  of  the  process, 

Fig.  44. 


m^'i 


Interior  of  pregnant  uterus  at  the  twenty-fifth  day.  Decidua  reflexa  cut  open  to  show  ovum, 
covered  witli  villi  of  the  chorion.  (Coste.)  dv,  decidua  vera  with  enlarged  uterine  glands; 
«,  uterine  wall ;  dr,  decidua  reflexa,  opened  and  turned  down,  showing  pitted  inner  surface ; 
right  ovary,  cut  open,  shows  corpus  luteum  with  folds. 


new  names  have  been  proposed :  decidua  reflexa  is  called  decidua 
capsularls,  and  decidua  serotina,  decidua  basilar  is  ;  but  the  old  names 
have  remained  in  more  common  use. 

The  decidua  vera  continues  to  grow  thicker  and  the  uterus  as  a 
whole  increases  in  mass  until  the  end  of  the  third  month,  but  after 
that   the    decidua   and    the    whole    uterine  wall    become   gradually 


CHORION.  31 

thinner.  The  decidiia  reflexa  also  grows  thicker  in  the  beginning, 
but  is  soon  expanded  by  the  growing  ovum,  and  at  tlie  end  of  three 
months  does  not  measure  over  a  millimetre  in  thickness.  It  has  no 
epithelium  and  its  blood-vessels  disappear  in  the  course  of  the  first 
three  months  of  pregnancy.  The  vera  also  loses  its  epithelium  and 
vera  and  reflexa  coalesce  more  or  less  completely,  so  that  the  former 
cavity  of  the  uterus  ceases  to  exist,  a  process  which  begins  towards 
the  end  of  the  third  month  and  is  finished  in  the  sixth  month.  At  the 
same  time  the  cervical  canal  is  closed  by  a  large  plug  of  thick  mucus. 


CHAPTER    II. 
CHORION. 


The  ovum  in  the  ripe  Graafian  follicle  measures  on  an  average  0.2 
of  a  millimetre,  and  the  youngest  fertilized  ovum  found  in  the  uterus, 
probably  one  week  old,  measured  in  its  longest  diameter  1.6  milli- 
metres,— that  is  to  say,  in  about  eight  days  it  had  become  eight  times 
longer.  The  above-described  segmentation  takes  place  in  mammaha, 
and  probably  in  woman,  during  the  passage  through  the  Fallopian 
tube.  At  the  same  time  small  branches  sprout  from  the  zona  pellucida 
of  the  ovum,  constituting  what  is  called  the  primitive  chorion^  which 
probably  offers  some  advantages  for  the  passage  of  the  ovum  along 
the  ciliated  surface  of  the  tubal  epithelium ;  but  it  soon  disappears 
and  is  replaced  by  ■  the  true  chorion,  a 
membrane  of  great  importance  in  the  his-  Fig,  45, 

tory  of  the  development  of  the  ovum  and  -  ---  ^  ^  j=f> 

the  foetus,  since  it  is  instrumental  in  form-         .'^^  _     J^y^ 

ing  the  connection  between  the  ovum  and  ^  "  v^        ^^^M}<^o 

the  uterus,  the  foetus  and  the  mother.     It  -  e    \H^ 

consists  of  two   layers,   an   external  one      /,     '  Tk     ^v^L 

composed  of  epithelial  cells,  the  e.^'oc/ioHo?i,       r  1(2/    \C^\ 

and  an  inner  one,  formed  of  fetal    con-       '-r.  i^V'ai 

nective  tissue,  the  endochorion.  'i^^'^!?^^■''  j\^^ 

The  whole  surface  of  the  ovum  be-  "^^  _^-^'<^^ 

comes    covered    with    sprouting    promi-  S-fll'i-'-v 

nences,    which    subdivide,    forming   little 
arborescent    tufts    inserted    with    a   thin         section  through  human  ovum  of 

.  about  two  weeks.     (Strahl.)     E,  em- 

pedicle  on  the  membrane  of  the  chorion,  bryo;2/,yoik-sac;cA,viiii of  chorion. 
the  so-called  villi  of  the  chorion  (Fig,  45), 

These  villi  consist  of  an  internal  stroma  of  connective  tissue  and  a 
double  layer  of  epithelial  character.  The  inner  is  called  the  ectoderm, 
and  consists  of  well-defined  cells,  each  with  a  nucleus ;  the  outer  is 
called  the  syncytium,  and  is  a  continuous  mass  of  protoplasm  \\\i\\ 


32 


NORMAL   PREGNANCY. 


Fig.  46. 


numerous  interspersed  nuclei  in  tlie  interior  and  liair-like  excrescences 
on  the  outer  surface.  Opinions  are  divided  as  to  the  origin  of  this 
layer,  some  believing  it  to  be  developed  from  the  epithelium  of  the 
uterus,  while  others  think  it  is  formed  from  the  ectoderm.  Probably 
both  the  epithelial  layers  of  the  villi  are  of  fetal  origin,  but  it  is  impos- 
sible to  draw  a  sharp  line  of  demarcation  between  the  fetal  and  the 
maternal  sphere.     The  two  epithelial  layers  are  not  found  uniformly 

all  over  the  surface  of  the 
villi ;  on  the  contrary,  in 
some  places  we  find  only 
regular  epithelium,  in  others 
syncytium,  and  in  others, 
again,  both. 

At  the  end  of  the  third 
or  the  beginning  of  the 
fourth  week  the  villi  are 
furnished  with  blood-ves- 
sels, each  villus  receiving 
an  arterial  branch,  which 
breaks  up  into  a  capillary 
net,  from  which,  again, 
starts  one  venous  branch 
(Fig.  46).  From  the  very 
beginning  of  the  embedding 
of  the  ovum  in  the  mucous 
membrane  of  the  uterus, 
the  villi  of  the  chorion 
enter  into  direct  connection 
with  the  maternal  tissue. 
In  monkeys  this  stage  has 
been  directly  observed. 
Cells  are  produced  in  large  quantity  on  the  tips  of  the  villi  and  form 
columns  that  perforate  the  epithelium  of  the  uterus  and  swell  up  at 
the  ends,  developing  little  buttons  in  the  tissue  of  the  decidua  (Fig. 
47).  Next  this  epithelium  of  the  decidua  melts,  forming  a  layer  of 
fibrin,  on  which  the  later  formed  branches  of  villi  are  inserted,  with- 
out entering  the  deeper  portions  of  the  mucous  membrane  (Fig.  48). 

In  the  above-mentioned  case  of  Peters  the  uterine  glands  are 
pushed  aside  by  the  ovum  and  do  not  open  into  the  cavity  containing 
it.  But  this  seems  to  be  accidental,  for  in  another  ovum  of  nearly 
the  same  age  described  by  Leopold  the  glands  not  only  connect  with 
that  cavity,  but  some  of  them  even  contain  villi.  The  presence  of 
that  thrombus  seen  at  the  top  of  the  ovum  may,  perhaps,  indicate 
some   abnormality  in  the  process,  but  another  and  more  plausLJDle 


Blood-vessels  of  a  r>ortion  of  a  villus  of  the  chorion 
(Li^geois.  Tarnier  et  Chantreuil,  Traite  de  I'Art  des  Ac 
couchements,  Paris,  Steinheil.)  1,  arterj%  and,  2,  vein 
united  by  arched  anastomoses  ;  3,  syncytium  ;  4,  stroma. 


CHORION. 


33 


(fc^ffi/. 


c: 


Ml, 


First  connection  between  the  ovum  and  the  uterus 
in  a  monkey.  (Selenka.)  F.,  yolk-sac  ;  ^wi.,  amnion; 
/.s.,  intervillous  spaces,  connected  with  arteries  and 
veins  and  filled  with  blood  ;  Ectod.,  ectodermal  pro- 
liferations at  the  ends  of  the  villi  of  the  chorion ; 
V,  V,  veins;  gl.,  uterine  glands;  Ar.,  artery,  and  v', 
vein,  opening  in  intervillous  spaces. 


explanation  is  that  the  ovum  originally  was  inserted  in  a  tear  of  the 
epithelium,  such  as  we  have  described  in  speaking  of  the  menstrual 
decidua.  It  is  not  likely  that  nature  would  restrict  the  possibility 
of  the  insertion  of  the  ovum 

within    unnecessarily    narrow  ^^^-  ^^• 

limits.  In  all  probability  it 
■does  not  make  any  difference 
whether  the  ovum  settles  on 
an  entire  or  a  torn  part  of  the 
epithelium,  Avhether  it  strikes 
the  opening  of  a  gland  or  the 
interglandular  surface.  Nature 
strives  to  perpetuate  all  its  cre- 
ations. 

The  room  between  the  villi, 
the  intervillous  spaces^  commu- 
nicates with  the  arteries  and 
veins  of  the  decidua,  the  endo- 
thelium of  which  vessels  also 
extends  over  the  inside  of  those 
spaces,  which  intercommuni- 
cate, but  are  closed  towards 
ihe  ovum.  Some  of  the  villi  are,  as  we  have  seen,  inserted  in  or  on 
the  decidua  and  serve  to  hold  the  ovum  in  \:)lace,^ixation-viIli  ; 
while  others  bathe  in  the  blood  circulating  in  the  intervillous  spaces 

and  absorb  nutritious  matter  for 
Fig.  48.  the  development  of  the  ovum 

and  foetus, — nutrition-villi. 

At  first  the  whole  ovum  is 
covered  with  villi  connecting 
with  the  decidua  serotina  and 
decidua  reflexa,  but  their  des- 
tination differs  much :  while 
those  of  the  serotina  grow  and 
acquire  large  proportions,  those 
connecting  with  the  decidua  re- 
flexa get  less  and  less  nourish- 
ment, atrophy,  and  disappear 
at  the  end  of  the  second  month 
of  gestation,  from  which  time 
the  chorion  offers  two  areas  of 
very  different  appearance,  the  shcu/gy  chorion,  or  chorion  frondosum, 
and  the  smooth  chorion,  or  chorion  Iceve. 

3 


fc^srww 


Artery 


First  insertion  of  the  villi  of  the  chorion  in  the 
■decidua.  Schematic.  (Mertens.)  An  artery  is  seen 
entering  the  intervillous  space  from  the  uterus. 


34 


NORMAL   PREGXAXCY. 


CHAPTER    III. 

PLACEXTA. 

The  placenta  is  the  organ  that  forms  the  communication  between 
the  mother  and  the  foetus.  While  that  part  of  the  chorion  that  is  in 
contact  with  the  serotina  becomes  more  and  more  developed  and 

Fig.  49. 


\>;    -  - 

Diagram  of  vertical  section  of  human  placenta.  (Bumm.)  tk.,  muscular  layer  of  uterus  ;  a.l.d., 
ampullar  laj-er  of  decidua ;  c.l.d.,  compact  layer  of  decidua  ;  D.  subch.,  deeidua  subchorialis  ;  ^.  dec, 
septa  extending  from  serotina  to  chorion ;  art.,  arteries  in  the  septa  opening  into  the  intervillous 
spaces;  v.,  v.,  tufts  of  chorion  with  fixation-viili  and  nutrition-villi ;  sin.,  sinuses,  or  intervillous 
spaces,  filled  with  blood,  the  dark  portions  representing  venous  blood  and  the  light  arterial  blood ; 
s.t,  sinus  terminalis. 

forms  new  branches  stretching  out  against  the  maternal  tissue,  this 
does  not  remain  inert.  Pegs  and  partition  walls  grow  out  from  the 
decidua,  enter  the  spaces  between  the  villi,  and  grow  together  with  the 
chorion,  forming  a  framework  which  affords  solidity  to  the  structure 


PLACENTA. 


35 


of  the  placenta.  In  the  neighborhood  of  the  circumference  of  the 
placenta  the  chorion  and  the  serotina  become  bound  together  by  the 
formation  of  what  is  known  as  the  decidua  placentalis  subchorialis,  or 


Fig.  50. 


Young  human  ovum  w  ith  germinal  disk  and  villi  of  the  chorion  bathed  in  the  blood  of  the 
intervillous  sinuses.  (Siegenbeck  van  Heukelom.)  j1,  vitelline  cavity;  B,  syncytium;  C,  hypo- 
blast ;  i>,  mesoblast ;  E,  cavity  of  amnion  ;  F,  chorion ;  G,  connective-tissue  stroma  of  villus. 

the  Schlussplatte  (occluding  layer)  of  Winkler  (Fig.  49),  a  flat,  circular 
layer  of  tissue  which  seals  the  placental  cavity.  The  uterine  epithe- 
lium is  lost  all  over  the  serotina,  and  in  the  subchorialis  the  decidua- 
cells  coalesce  with  the  chorion.  The  intervillous  spaces  remain  in 
direct  communication  with  the  maternal  arteries  and  veins,  so  that 


Fig.  51. 


Transverse  section  of  a  villus  of  the  chorion  at  the  end  of  pregnancy.    (Eckardt.)    Spaces  filled 
with  fetal  blood  lie  in  the  stroma,  which  is  covered  with  the  epithelium  of  the  chorion. 

the  villi  are  constantly  bathed  in  maternal  blood  (Fig.  50).  On  the 
other  hand,  the  fetal  blood  circulates  in  vessels  tunnelling  each  villus 
(Fig.  51).    Nowhere  is  there  a  direct  communication  between  maternal 


36 


NORMAL   PREGNANCY. 


and  fetal  blood,  but  the  barripr  between  the  two  is  formed  only  by  the 
stroma  and  the  epithelium  of  the  villi. 

From  the  third  month  giant  cells  appear  among  the  decidua-eells 
and  become  more  numerous  as  pregnancy  progresses.  They  wander 
into  the  intervillous  spaces  and  gradually  fill  them,  so  as  to  limit  the 
blood-supply  more  and  more, — the  thrombosis  of  the  sijmses, — thus 
preparing  for  the  time  when  the  connection  between  mother  and  child 
shall  cease. 


CHAPTER    IV. 

DEVELOPMENT  OF  THE  OVUM  AND  THE  EMBRYO. 

In  regard  to  the  details  of  the  development  of  the  embryo  and 
foetus  the  reader  is  referred  to  works  on  emlDryology ;  but  there  are 
features  of  the  ovum  which  could  not  be  understood  unless  we  com- 
prehended in  our  description  an  outline  of  the  earlier  stages  of  fetal 
development;  and  as  it  is  also  of  practical  importance  for  the  obste- 
trician to  be  able  to  tell  the  age  of  a  foetus  expelled  by  abortion,  we 
shall  add  the  chief  stages  of  development  attained  at  regular  intervals 
of  about  four  weeks. 

We  left  the  ovum  at  the  moment  when  the  ectomeres  had  closed 
around  the  entomeres  and  a  fluid  had  accumulated  between  the  two, 

Fig.  52. 


Transverse  section  through  the  anterior  end  of  the  primitive  streak  and  blastoderm  of  the  chick. 
(Balfour.)    pr,  primitive  groove ;  7>i,  mesoblast ;  ep,  epiblast ;  fti/,  hypoblast. 

except  on  a  small  area,  Avhere  they  remained  in  contact.  This  part  is 
called  the  germinative  disk,  or  blastos,  because  from  it  the  embryo  is 
formed.  The  whole  ovum  is  called  the  hJastodermw  vesicle  (corre- 
sponding to  the  blastoderm  in  the  chick) ;  the  outer  layer  of  cells  is 
named  the  ectoderm,  and  the  inner  the  entoderm.  Between  these  two 
soon  appears  a  third  layer,  the  mesoderm.  Within  the  germinative  area 
these  different  layers  are  respectively  termed  the  epiblast,  the  hijpobJast, 
and  the  mesoblast  (Fig.  52).  The  inner  part  of  the  germinal  disk 
remains  transparent  and  is  denominated  the  area  pellucida,  while  the 
outer  becomes  darker  and  is  designated  the  area  opaca. 

The  first  sign  of  the  development  of  the  fetal  body  is  the  appear- 


DEVELOPMENT  OF  THE  OVUM  AND  THE  EMBRYO. 


37 


ance  of  a  thicker,  lengthy,  and  narrow  part  caHed  the  primitive  streak. 
The  edges  growmg  upward,  a  central  depression  is  formed,  the  so- 
caWed  primitive  groove  (Figs.  53,  54).  The  primitive  streak  and  groove 
are  evanescent  organs  and  do  not  form  any  portion  of  the  embryo, 
but  in  front  of  the  primitive  groove  a  similar  but  larger  formation 
takes  place,  a  groove  in  the  middle,  called  the  medullary  groove,  and 
two  lateral  ridges,  the  medullary  folds,  which  grow  together  in  front 
and  enclose  the  primitive  streak  behind  (Fig.  55).  The  ridges  extend 
upward  and  unite,  forming  the  medullary  canal,  the  beginning  of  the 
nervous  system. 


Fig.  53. 


Fk4.  54. 


/>r.s 


Transparent  area  of  the  blastoderm  of  a 
chick  at  a  very  early  period,  showing  the  com- 
mencement of  the  primitive  streak.  (Balfour. ) 
pr.s,  primitive  streak ;  op,  area  pellucida ;  a.op, 
area  opaca. 


-j>r 


Pyriform  area  pellucida  of  the  chick's  blas- 
toderm, with  the  primitive  groove.  (Balfour.) 
pr,  primitive  streak  and  groove ;  af,  amniotic 
fold  commencing  ;  the  darker  shading  around 
the  primitive  streak  indicates  the  extension  of 
the  mesoblast. 


The  nervous  system,  as  well  as  the  epidermis,  is  formed  by  the 
epiblast.  The  hypoblast  forms  the  glandular  part  of  the  intestine. 
The  mesoblast  separates  into  an  inner  column,  that  is  the  foundation 
of  the  craniovertebral  skeleton  and  the  associated  voluntary  muscles, 
and  an  outer  portion,  which,  again,  splits  into  an  upper  and  a  lower 
layer,  the  parietal  or  somatie  plate  and  the  visceral  or  splanchnic  plate, 
also  respectively  called  the  somatopleure  and  the  splanchnopleure  (Fig. 
56).  Of  these  the  upper  together  with  the  epiblast  gives  origin  to  the 
amnion,  a  membrane  surrounding  the  embryo,  and  the  lower  together 
with  the  hypoblast  forms  two  other  membranes,  which  are  in  direct 
continuity  with  the  wall  of  the  alimentary  canal, — viz.,  the  yolk-sac 
and  the  allantois  (Fig.  57). 

The  embryo,  which  at  first  is  represented  by  a  flat  disk  on  a  small 
part  of  the  blastodermic  vesicle,  closes  gradually  from  side  to  side 
(Fig.  56)  and  becomes  curved  by  the  approach  of  the  cephalic  ex- 
tremity and  the  caudal  end  towards  each  other  (Fig.  57). 


NORMAL   PREGNANCY. 


Fig.  55. 


Surface  view  of  the  transparent  area  of  the  blastoderm  of  a  chick  eighteen  hours  old.  (Bal- 
four.) pr,  primitive  groove,  closed  in  front  by  the  coalescence  of  the  two  lateral  ridges;  mc, 
medullary  groove,  having  on  each  side  a  medullary  fold  or  ridge,  A,  which  also  meet  in  front  so  as 
to  close  the  groove,  but  diverge  behind,  enclosing  the  primitive  streak  ;  in  front  the  fold  of  the 
amnion  is  commencing. 


Transverse  section  through  the  embryo  chick  before  and  some  time  after  the  closure  of  the 
medullary  canal,  to  show  the  upward  and  downward  inflections  of  the  blastoderm.     (Remak.) 

A,  at  the  end  of  the  first  day:  1,  notochord  (the  rudimentary  spinal  column)  ;  2,  medullary 
canal ;  3,  edge  of  the  dorsal  lamina,  which  forms  the  commencement  of  the  brain  and  spinal  mar- 
row ;  4,  epiblast;  5,  mesoblast,  divided  into  upper  and  lower  plates  ;  6,  hypoblast ;  7,  section  of  pro- 
tovertebral  somite. 

S,  on  the  third  day  in  the  lumbar  region  :  1,  notochord  in  its  sheath  ;  2,  medullary  canal  closed  ; 
3,  section  of  the  medullary  substance  of  the  spinal  cord  ;  4,  cuticular  layer  of  epiblast ;  5,  somatic 
(or  parietal)  mesoblast;  5',  visceral  mesoblast;  6,  hypoblast  layer  in  the  intestine  and  spreading 
over  the  yolk ;  4  X  5,  epiblast  and  somatic  mesoblast  going  to  form  the  amnion ;  5',  6,  visceral 
mesoblast  and  hypoblast  passing  into  the  yolk-sac. 


DEVELOPMENT  OF  THE  OVUM  AND  THE  EMBRYO. 
Fig.  57. 


39 


Five  schematic  figures,  showing  the  development  of  the  fetal  membranes.  The  foetus  is  repre- 
sented in  longitudinal  section.    (Kolliker.) 

1.  Ovum  in  which  the  chorion  has  begun  to  be  formed,  with  blastodermic  vesicle,  germinative 
disk,  and  the  substratum  of  the  embryo,  a,  thickening  of  epiblast,  part  of  embryonal  rudiment; 
b,  thickening  of  mesoblast,  going  to  form  part  of  embryo  ;  c,  blastodermic  vesicle,  outer  layer  ;  &, 
blastodermic  vesicle,  inner  layer ;  d,  extension  of  mesoblast  between  the  two  layers  of  the  blasto- 
dermic vesicle ;  e,  vitelline  membrane,  or  primitive  chorion ;  /,  commencing  villi  of  chorion ;  g, 
cavity  of  the  blastodermic  vesicle,  becoming  later  the  cavity  of  the  yolk-sac. 

2.  Ovum  with  beginning  formation  of  amnion  and  yolk-sac.  h,  embryo ;  i,  cephalic  fold  of 
amnion  ;  j,  caudal  fold  of  amnion  ;  k,  cavity  of  yolk-sac  ;  I,  vitelline  duct ;  m,  hypoblast ;  ?!.,  wall 
of  the  thorax  in  the  region  of  the  heart ;  o,  sinus  terminalis,  circumference  of  the  vascular  area  in 
the  early  stages.     Other  letters  as  in  1. 

3.  Ovum  with  closing  amnion  and  sprouting  allantois.  p,  amnion;  p'.  cavity  of  amnion; 
q,  false  amnion  ;  r,  allantois.     Other  letters  as  in  1  and  2. 

4.  Ovum  in  which  the  amnion  is  closed,  the  true  amnion  surrounding  the  embryo,  the  false 
amnion  combining  with  the  chorion,  s,  villi  of  the  chorion  more  advanced  ;  t,  space  between  amnion 
and  chorion,  containing  an  albuminous  fluid  ;  u,  pericardial  cavity.    Other  letters  as  in  2  and  3. 

5.  Ovum  in  which  the  vascular  layer  of  the  allantois  has  spread  over  the  false  amnion,  and  its 
vessels  have  grown  into  the  villi  of  the  chorion,  constituting  the  true  chorion  ;  the  yolk-sac  is  atro- 
phied and  the  cavity  of  the  amnion  is  increasing  in  size,  v,  true  chorion;  iw,  villi  of  the  true 
chorion  more  advanced  ;  x,  sheath  of  navel-string  formed  by  amnion.  Other  letters  as  in  preceding 
figures. 


40 


NORMAL   PREGNANCY. 


CHAPTER   V. 
AMNION. 

At  a  very  early  stage,  as  soon  as  the  primitive  streak  has  appeared 
(Fig.  54),  a  fold  is  raised  from  the  epiblash  and  mesoblast  at  the 
cephalic  end  of  the  embryo  ;  a  similar  fold  is  thereafter  formed  at  the 
caudal  end ;  these  are  called  the  cephalic  and  caudal  folds  of  the 
amnion.     Gradually  this  process  extends  around  the  whole  embryo, 


Enlarged  diagrammatic  outline  of  a  longitudinal  vertical  section  of  the  chick  and  neighboring 
parts  of  the  blastoderm  on  the  fourth  day.  (Allen  Thomson.)  ep,  epiblast;  sm,  parietal  meso- 
blast ;  hy,  hypoblast ;  vm.,  visceral  mesoblast ;  af,  cephalic  fold ;  pf,  caudal  fold  of  amnion ;  am, 
cavity  of  the  true  amnion ;  ys,  yolk-sac;  vi,  vitello-intestinal  aperture,  or  vitelline  duct;  i,  intes- 
tine ;  s,  stomach  and  gullet ;  o,  the  future  anus,  still  closed ;  m,  the  mouth,  still  closed ;  me,  mes- 
entery ;  al,  allantois ;  pp,  space  between  the  outer  and  inner  layers  of  the  amnion.  The  epiblast 
and  hypoblast  are  drawn  with  entire  lines,  the  parietal  mesoblast  with  an  interrupted  line,  and  the 
visceral  mesoblast  with  a  dotted  line. 

and  the  fold  rises  more  and  more  (Fig.  58)  until  finally  it  closes  over 
the  back  of  the  embryo  and  separates  into  its  two  layers,  the  true  and 
the  false  amnion.  The  true  amnion  forms  at  first  an  involucrum  in 
contact  with  the  embryo,  but  by  and  by  a  fluid,  liquor  amnii,  col- 
lects between  it  and  the  embryo.  The  false  amnion  applies  itself  to 
the  inside  of  the  chorion,  with  which  it  blends. 


CHAPTER   VI. 
THE   ALLANTOIS. 

Our  knowledge  of  the  allantois  is  based  on  observations  upon 
animals.  In  them  it  is  a  vesicle  growing  out  from  the  posterior  part 
of  the  intestine  (Figs.  57,  58,  and  59),  with  which  its  cavity  commu- 
nicates. It  plays  an  important  part  in  the  nutrition  of  the  ovum  and 
the  foetus  by  carrying  blood-vessels  to  the  villi  of  the  chorion,  some 
of  which  participate  in  the  formation  of  the  placenta ;  but  it  soon 


THE    YOLK-SAC. 


41 


ceases  to  be  a  hollow  bag,  and  in  the  human  ovum  its  cavity  perhaps 
never  extends  beyond  the  umbilicus.     That  part  of  it  which  is  situ- 


FiG.  59. 


Longitudinal  section  fhrough  the  posterior  end  of  an  emferyo  chick  of  two  days  and  sixteen 
hours.  Beginning  formation  of  the  allantois.  Enlargement  thirty-five.  (Kolliker.)  g,  posterior 
entrance  to  gut ;  g' ,  end  of  hind-gut ;  al,  cavity  of  allantois  ;  aV ,  protuberance  of  allantois  ;  vd,  wall 
of  the  later  vitelline  duct ;  i.b,  transition  of  the  intestinal  wall  into  the  deeper  parts  of  the  blasto- 
derm, which  later  form  the  yolk-sac  ;  am,  origin  of  amnion  from  the  posterior  end  of  the  substratum 
of  the  allantois ;  i,  tail ;  at  the  bottom  of  the  fold  between  the  amnion  and  the  tail  opens  later  the 
anus ;  d,  protuberance  of  the  cloaca ;  nc,  notochord ;  mc,  medullary  canal ;  ps,  protovertebral 
somites. 

ated  inside  of  the  embryo  remains  hollow  and  becomes  the  urachus 
and  the  bladder. 


CHAPTER   VII. 

THE   YOLK-SAC,    OR   UMBILICAL   VESICLE. 

A  GLANCE  at  Fig.  57  shows  that,  while  at  first  the  blastodermic 
vesicle  contains  a  cavity  which  on  section  has  the  shape  of  a  circle, 
this  is  soon  changed  to  a  figure-of-eight.  The  upper,  smaller  portion 
of  the  cavity  is  embedded  in  the  body  of  the  embryo,  where  it  event- 
ually becomes  the  lumen  of  the  intestine,  while  the  larger  remains 
in  the  ovum  proper,  and  is  called  the  yolk-sac.  This  partition  of  the 
cavity  is  caused  by  the  above-mentioned  curvature  of  the  embryo,  in 
consequence  of  which  the  communication  between  the  two,  the  vitelline 
duct,  or  omphalo-enteriG  duct,  becomes  narrower  and  narrower,  until  it 
finally  is  closed  by  the  formation  of  the  umbilicus.  Thence  it  extends 
in  the  shape  of  a  filament  through  the  umbilical  cord,  and  leads  to  a 
little  vesicle  found  near  the  periphery  of  the  placenta,  even  at  the  end 


42 


NORMAL    PREGNANCY. 


of  pregnancy.  The  yolk-sac  consists,  like  the  intestine,  of  two  layers, 
an  inner  epithelial  layer,  formed  of  the  inner  layer  of  the  blastodermic 
vesicle,  and  an  outer  layer,  derived  from  the  visceral  layer  of  the 
mesoblast  (Figs.  57,  58).  Physiologically  it  is  a  store-room,  containing 
food  enough  for  the  foetus  until  the  placenta  is  sufficiently  developed 
to  bring  a  constantly  changing  supply. 


CHAPTER   y  11 1. 

FORMATION    OF   THE    UMBILICAL   CORD. 

The  remnants  of  the  vitelline  duct  and  the  yolk-sac,  two  umbilical 
arteries  and  one  umbilical  vein  leading  to  and  from  the  placenta,  and 
a  gelatinous  mass  called  the  gelatin  of  Wharton,  all  covered  with  a 
sheath  furnished  by  the  amnion  (Fig.  57,  5),  form  a  cord,  called  the 
umbilical  cord,  or  navel-string,  which  allows  the  embryo  to  move 
freely  in  the  liquor  amnii  and  is  the  connecting  link  between  the 
mother  and  the  child.     The  string-like  shape  of  the  organ  is  brought 


Schematic  representation  of  the  formation  of  the  umbilical  cord  and  its  central  insertion. 
(Ahlfeld.)  Refl.,  decidua  reflexa  ;  Serot,  decidua  serotina  ;  a,  cephalic  fold  of  amnion  ;  r,  umbilical 
vesicle  ;  A,  the  back  of  the  embryo  turned  towards  the  serotina  ;  B,  embryo  partly  turned  ;  C,  the 
turning  being  accomplished,  the  ventral  surface  of  the  embrj'o  is  nearest  to  the  serotina. 


about  gradually  by  the  accumulation  of  liquor  amnii  and  the  conse- 
quent extension  of  the  amnion,  until  it  closes  in  on  the  two  other 
sacs,  the  allantois  and  the  yolk-sac.  In  the  beginning  there  is  only  a 
short,  thick  stalk,  called  the  yolh-stcdh,  or  abdominal  stalk,  by  which  the 
foetus  is  connected  with  the  chorion  (see  Figs.  65,  67,  68,  69,  70), 
and  into  which  the  allantois  grows. 

Probably  the  germinative  disk,  by  a  provision  of  nature,  as  a  rule, 
develops  on  the  part  of  the  ovum  opposite  to  the  decidua  serotina,  so 


NUTRITION.  43 

that  its  ventral  aspect  is  turned  towards  tlie  placenta,  as  represented 
in  Fig.  57,  5,  just  as  the  blastoderm  of  a  chick  always  turns  to  the 
top  of  the  egg,  where  it  is  most  favorably  exposed  to  the  maturing 
influence  of  the  heat  given  off  by  the  hatching  hen.  If  such  a  dis- 
position does  not  exist  in  man,  the  embryo  must  turn  inside  of  the 
ovum,  as  represented  in  Fig.  60,  A,  B,  C,  a  turning  which  is  brought 
about  by  a  preponderance  in  growth  of  the  cephalic  fold  of  the  amnion 
and  pressure  on  the  corresponding  part  of  the  allantois,  by  which  this 
is  made  to  atrophy. 

The  blood-vessels  of  the  serotina  being  more  developed  than 
those  of  the  reflexa,  nourishment  is  more  plentiful  here,  and  the  result 
is  a  central  insertion  of  the  navel-string  on  the  placenta.  That  such 
a  process  really  takes  place,  at  least  occasionally,  is  proved  by  the 
aberrations  from  the  normal  course,  resulting  in  an  excentric  insertion 
on  the  placenta  or  even  an  insertion  on  the  membranes. 

Between  the  chorion,  the  amnion,  the  allantois,  and  the  yolk-sac 
is  found  an  albuminous  fluid,  which  gradually  becomes  inspissated 
and  on  preserved  specimens  looks  like  a  membrane.  This  substance 
is  known  as  the  tunica  media,  or  membrana  intermedia,  of  Bischoff,  or 
the  magma  raticide  of  Velpeau. 


CHAPTER    IX. 
NUTRITION. 

The  ovum  contains  in  its  vitellus  nourishing  substances,  but  these 
would  soon  be  exhausted  if  they  were  not  renewed.  At  first  the 
ovum  and  the  embryo  receive  the  material  needed  for  their  develop- 
ment by  mere  endosmosis  from  the  maternal  tissues  with  which  the 
ovum  is  in  contact ;  and  m  this  connection  it  may  be  well  to  remem- 
ber the  fine  villi  that  sprout  out  on  the  surface  of  the  zona  pellucida 
while  the  ovum  is  still  on  its  way  from  the  ovary  to  the  uterus. 
These  increase  materially  the  surface  area  of  the  ovum,  and  are  par- 
ticularly fit  to  absorb  fluid,  like  the  rootlets  of  a  germinating  plant. 

At  a  later  stage  of  development,  when  the  true  chorion  is  formed 
and  its  villi  with  their  blood-vessels  grow  into  the  decidua  reflexa 
and  serotina,  nourishment  is  derived  through  them  from  the  maternal 
blood.  Still  later,  after  the  formation  of  the  placenta  and  the  disap- 
pearance of  the  villi  corresponding  to  the  reflexa,  the  whole  nutrition 
takes  place  through  the  placenta. 

As  we  have  seen  above,  there  is  nowhere  a  direct  communication 
between  the  blood  of  the  mother  and  that  of  the  foetus.  The  villi  of 
the  chorion  bathe  in  the  blood  of  the  intervillous  spaces,  but  they  are 


44  NORMAL   PREGNANCY. 

covered  all  over  with  a  single  or  in  most  places  even  with  a  double 
layer  of  epithelium,  and  the  fetal  arteries  communicate  only  with  fetal 
veins.  But  if  under  ordinary  circumstances  there  is  no  direct  com- 
munication, a  lively  interchange  of  substances  takes  place  between 
mother  and  child  by  osmosis  through  the  walls  of  the  villi  of  the 
chorion  and  of  the  blood-vessels  in  their  interior. 

In  this  way  gaseous  and  fluid  substances  are  transferred.  Ether 
given  to  the  parturient  mother  may  be  recognized  by  the  smell  im- 
parted to  the  breath  of  the  new-bom  babe.  Chloroform  and  oxide 
of  carbon  have  been  shown  to  pass  from  the  mother  to  the  foetus. 

The  blood  in  the  umbilical  vein  is  of  a  bright-red  color  and  that 
in  the  umbilical  arteries  is  dark,  the  difference  evidently  being  attrib- 
utable to  the  presence  of  a  large  amount  of  oxygen  in  the  former  and 
of  carbonic  acid  in  the  latter.  This  conclusion  has  been  corroborated 
by  quantitative  chemical  examination  of  the  blood  circulating  in  the 
different  vessels. 

Different  drugs,  such  as  iodide  of  potassium,  salicylic  acid,  and 
ferrocyanide  of  potassium,  administered  to  the  mother,  have  been 
found  in  the  foetus.  Thus  medicinal  substances  taken  by  the  mother 
may  affect  her  unborn  child.  This  is  notably  the  case  with  opium, 
mercury,  copper,  lead,  arsenic,  and  the  iodides. 

While  thus  we  are  warranted  in  stating  in  a  general  way  that  all 
gaseous  substances  and  those  soluble  in  water  can  pass  the  barrier 
between  the  maternal  and  fetal  organisms,  the  statement  does  not  apply 
to  solid  bodies,  even  of  very  small  dimensions.  On  the  contrary,  there 
is  ample  reason  to  believe  that  no  solid  body,  be  it  ever  so  little,  can 
pass  through  the  normal  placenta.  To  this  effect  numerous  experi- 
ments have  been  made  with  substances  that,  on  account  of  their  color, 
are  easily  recognizable,  such  as  cinnabar,  madder,  and  India  ink.  These 
experiments  have  so  often  given  a  negative  result  that  the  conclusion 
seems  warranted  that  in  the  exceptional  cases  in  which  a  transfer 
took  place  it  was  due  to  a  minute  injury  of  the  epithehum  of  the  villi 
of  the  chorion.  Not  even  the  physiological  emulsion  of  fat  absorbed 
by  the  villi  of  the  intestine  can  pass  those  of  the  chorion.  In  a  case 
of  lucocythaemia  the  fetal  blood  remained  unchanged,  showing  that 
the  white  blood-corpuscles  did  not  pass  from  mother  to  child,  while 
the  red  blood-corpuscles  are  normally  much  more  numerous  in  fetal 
than  in  maternal  blood,  which  proves  that  they  do  not  pass  from  one 
to  the  other. 

New  interest  has  been  added  to  the  question  about  the  possi- 
bility of  the  passage  of  solids  from  the  mother  to  the  child  since  we 
know  that  in  certain  catching  diseases  the  infection  is  caused  by 
micro-organisms.  Thus,  the  microbes  of  typhoid  fever,  pneumonia, 
tuberculosis,  and  vaccinia,  as  v>'ell  as  staphylococci,  streptococci,  and 


SECRETION   AND   EXCRETION.  45 

bacillus  coli  communis,  have  been  found  in  the  foetus,  where  they 
could  come  only  from  the  mother.  But  since  these  cases  are  com- 
paratively rare  and  we  here  deal  with  pathological  conditions,  the 
above  reasoning  not  only  holds  good,  but  its  correctness  is  even  cor- 
roborated,— namely,  that  the  migration  of  these  microbes  from  the 
maternal  to  the  fetal  placenta  occurs  only  when  there  is  an  abnormal 
solution  of  continuity  in  the  latter. 

Another  source  of  nutritive  elements  is  the  liquor  amnii,  an  albu- 
minous fluid,  of  which  the  foetus  swallows  large  quantities,  as  proved 
by  the  presence  of  an  abundance  of  a  black  or  dark -green,  tarry  mass, 
called  meconium.,  in  the  lower  part  of  the  intestine  of  the  new-born 
child,  containing  hairs  and  epidermis-cells  which  have  been  detached 
from  its  skin.  The  amount  of  this  substance  is  so  large  that  it  prob- 
ably serves  to  determine  the  formation  of  the  cavity  of  the  pelvis  ;  and 
if  we  compare  the  different  degrees  of  density  between  the  watery 
liquor  amnii  and  the  tarry  meconium  we  can  imagine  that  large 
amounts  of  the  former  have  been  needed  to  form  the  latter,  even  if 
we  take  into  consideration  the  fact  that  bile  and  intestinal  epithelium 
form  part  of  it. 


CHAPTER    X. 
SECRETION    AND    EXCRETION. 

We  have  already  mentioned  that  the  carbonic  acid  of  the  blood 
passes  from  the  fetal  to  the  maternal  vessels.  The  same  is  in  all 
likelihood  the  case  with  effete  matter  of  the  fetal  body.  That  such  a 
transfer  takes  place  from  the  foetus  to  the  mother  has  been  proved 
experimentally  by  injecting  strychnine  into  the  foetus  of  an  animal 
and  thereby  poisoning  the  mother. 

Bile  is  secreted  by  the  liver  and  forms  part  of  the  meconium.  In 
the  stomach  are  found  pepsin  and  rennet. 

In  regard  to  the  function  of  the  kidneys  opinions  differ.  Formerly 
the  liquor  amnii  was  believed  to  be  the  fetal  urine  excreted  by  the 
urinary  organs,  but  this  theory  has  met  with  much  adverse  observa- 
tion and  argument.  The  criticism  that  it  would  seem  strange  if  the 
foetus  should  be  suspended  nine  months  in  its  own  urine  and  drink 
it  and  give  it  off  again  is  not  so  forcible  as  it  may  appear  at  the  first 
glance,  because,  as  we  shall  presently  see,  a  somewhat  similar  arrange- 
ment actually  exists  in  regard  to  the  fetal  blood.  But  the  amount 
of  urea  found  in  the  liquor  amnii  at  term  is  very  small  (0.03-0.04  per 
cent.),  and  in  cases  of  early  premature  birth  there  is  none  at  all.  The 
pressure  in  the  fetal  arteries  is  so  small  compared  with  that  exercised 
by  the  uterus  on  the  ovum  that  not  much  urine  could  be  secreted  by 


46  NORMAL   PREGNANCY. 

the  kidneys  and  made  to  fill  the  bladder.  Most  of  the  instances  that 
have  been  alleged  as  proof  of  accumulation  of  large  amounts  of  urine 
in  the  bladder  were  cases  of  atresia  ani  vesicalis,  in  which  the  fluid 
may  have  come  from  the  intestine  and  the  liquor  amnii  and  not  from 
the  kidneys.  In  a  case  of  premature  rupture  of  the  membranes,  with 
living  foetus,  the  liquor  amnii  was  repeatedly  examined  during  thirty- 
one  days,  and  contained  only  traces  of  urea.  It  seems,  therefore,  to 
be  proved  that  the  liquor  amnii  is  not  fetal  urine  ;  but  that  occasion- 
ally, especially  towards  the  end  of  pregnancy,  some  urine  mixes 
with  it.  It  originates  chiefly  in  the  mother  and  reaches  the  foetus 
by  exudation. 


CHAPTER    XI. 
RESPIRATION. 


During  fetal  life  the  placenta  is  the  exclusive  organ  of  respiration. 
In  the  villi  of  the  chorion  and  the  intervillous  spaces  filled  with 
maternal  blood  the  interchange  of  substances  between  the  foetus  and 
the  mother  takes  place,  the  former  giving  off  carbonic  acid  and  ab- 
sorbing oxygen. 


CHAPTER    XII. 

CIRCULATION. 


During  fetal  development  and  shortly  after  the  birth  of  the  child 
three  different  systems  of  circulation  are  in  use,  and,  as  might  be  ex- 
pected, the  transition  from  one  to  the  other  is  not  abrupt,  but  one 
gradually  replaces  the  other. 

The  human  heart  develops  early.  It  is  discernible  and  shows 
rhythmic  contractions  a  few  hours  after  the  formation  of  the  primitive 
streak,  but  does  not  at  that  early  period  communicate  with  the  blood- 
vessels, so  that  there  is  no  circulation  until  later,  when  the  blood- 
vessels, formed  independently,  connect  with  the  heart. 

The  first  embryoniG  circulation  takes  place  in  the  yolk-sac.  The 
blood  goes  from  the  two  primitive  aortse,  or  inferior  vertebral  arteries, 
through  the  omphalomesenteric  arteries  to  the  upper  part  of  the 
umbilical  vesicle, — that  is,  that  portion  of  it  which  is  nearest  the 
embryo, — and  returns  through  the  sinus  terminalis  and  the  omphalo- 
mesenteric veins  to  the  sinus  of  the  heart  (Figs.  61,  62).  Later  the 
two  inferior  vertebral  arteries  blend,  forming  the  abdominal  aorta. 
The  omphalomesenteric  arteries,  which  in  the  beginning  are  numer- 


CIRCULATION. 


47 


ous,  atrophy  and  are  reduced  to  two,  and  fnially  to  one,  the  right 
omphalomesenteric  artery. 

The  first  circulation  takes  place  in  the  following  way.  The  heart 
contracts  (systole),  propelling  the  blood  into  the  aorta,  whence  it 
enters  the  vertebral  arteries,  and  from  them  goes  to  tlie  omphalo- 
mesenteric arteries,  which  distribute  it  over  the  vascular  area  of  the 
umbilical  vesicle  in  capillary  vessels.  The  blood  takes  up  nutritive 
elements  from  the  vitellus,  and  returns  through  the  sinus  terminalis, 
the  omphalomesenteric  veins,  the  sinus  of  the  heart,  and  the  heart 
itself,  which  it  finds  relaxed  (diastole).     This   system  of  circulation 

Fig.  61. 


The  first  embryonic  circulation  in  the  vascular  area  of  the  yolk-sac  of  a  rabbit.  (Bischoff.)  1, 
sinus  terminalis;  2,  omphalomesenteric  vein;  3,  lower  branch  of  the  same;  4,  heart,  bent  like 
an  s;  5,  primitive  aortse,  or  inferior  vertebral  arteries;  6,  omphalomesenteric  arteries;  7,  primary 
optic  vesicles. 

exists  only  a  short  time.  At  the  end  of  the  fifth  week  it  has  already 
begun  to  give  way  to  the  second  circulation,  that  of  the  placenta. 

The  second  embryoniG  circulation  is  brought  about  by  means  of  the 
allantois,  that  other  sac  which  protrudes  from  the  abdominal  surface 
of  the  foetus.  This  carries  blood-vessels  to  all  the  villi  of  the  chorion, 
but,  as  we  have  seen  above,  those  implanted  in  the  decidua  reflexa 
soon  become  atrophied  and  disappear,  while  those  entering  the  decidua 
serotina  flourish  and  acquire  such  dimensions  that  they  make  up  the 
bulk  of  the  placenta  at  term. 

At  the  time  this  second  circulation  is  established  tlie  lieart  has  be- 
come divided  into  auricles  and  ventricles,  but  between  the  two  auricles 
there  is  an  opening,  the  foramen  of  Bofallo,  or  foramen  ovale.     The 


48 


NORMAL    PREGXANX'Y. 


pulmonary  arteries  have  been  formed,  but  they  communicate  Avith 
the  aorta  through  tlie  (Juctus  arteriosus  of  BotalJo.  Finally,  the  liver 
and  the  vena  porta  have  been  formed.  The  vena  porta  is  that  part 
of  the  omphalomesenteric  vein  -svhich  comes  from  the  intestine  and 
opens  into  the  right  advehent  hepatic  vein.  The  other  portion  which 
is  distributed  over  the  yolk-sac  becomes  smaller  and  smaller  and 
disappears.     The  umbilical  vein  anastomoses  with  the  ven?e  hepaticse 


First  embrvonic  circulation  a  little  laten  (Tarnier  et  Chantreuil,  1.  c.)  a.  allantois,  justTDUd- 
•ding;  6,  6,  6.  omphalomesenteric  arteries,  coming  from  the  two  primitive  abdominal  aortse,  or  infe- 
rior vertebral  arteries;  om,  om,  the  two  trunts  of  the  omphalomesenteric  veins  ;  s,  sinus  of  heart; 
c,  heart. 

advehentes,  and  from  this  pomt  a  large  canal,  the  ductus  venosus  of 
Aranzi.  leads  to  the  vena  cava  inferior  (Figs.  63,  64). 

In  the  second,  or  placental,  circulation  the  blood  moves  in  the 
followmg  way.  From  the  left  ventricle  it  goes  through  the  ascending 
aorta  and  the  arch  of  the  aoria,  and  simultaneously  from  the  right 
ventricle  through  the  pulmonary  artery.  The  blood  from  the  aorta 
goes  to  the  innominate  artery,  the  left  carotid,  and  the  left  subclavian 
artery,  supplying  the  head  and  the  upper  extremities.  Of  that  com- 
ing through  the  pulmonary  artery  only  a  little  enters  the  still  small 
branches  of  that  artery  ramifying  in  the  two  lungs :  by  far  the  greater 
portion  goes  through  the  duct  of  Botallo,  the  descending  aorta,  and 
the  common  iliac  arteries.  Where  these  bifurcate,  the  smaller  portion 
passes  through  the  external  iliac  artery  to  the  lower  extremity,  and 
the  much  larger  flows  through  the  internal  ihac  artery  and  its  con- 
tinuation, the  umbilical  artery,  to  the  placenta,  where  oxygenation 
takes  place  by  contact  with  the  maternal  blood.  x\s  we  have  seen 
above,  not  a  drop  of  blood  passes  from  the  mother  to  the  foetus,  but 
the  oxygen  in  the  maternal  blood  is  transmitted  through  the  fine 
membrane  separating  the  blood  circulating  in  the  villi  of  the  chorion 
from  that  circulating  m  the  intervillous  blood-spaces  of  the  maternal 


Fig.  63. — Second  fetal,  or.  placental  circulation.  1,  tetal  surface  of  placenta, 
on"  one-half  of  which  the  amnion  has  been  removed,  showing  the  branches  of 
the  umbilical  A-ein  (red)  and  the  umbilical  arteries  (purple)  ;  2,  chorion  ;  3, 
amnion  ;  4,  umbilical  cord  ;  5,  umbilicus,  where  the  vessels  of  the  cord  separate  ; 
6,  umbilical  vein  ;  7,  -advehent  hepatic  vein  ;'  8,  trunk  of  vena  porta  ;  9,  venous 
duct  of  Aranzi  ;  10,  anastomosis  between  the  venous  duct  and  the  vena  cava 
inferior  ;  11,  vena  cava  inferior  above  the  diaphragm  ;  12,  right  auricle  of  heart  ; 
13,  ventricles  of  heart  ;  14,  vena  cava  superior  ;  15,  ascending  aorta  ;  16,  pul- 
monary artery  ;  17,  right  and  left  pulmonary  branches  of  the  same  ;  18,  arterial 
duct  of  Botallo  ;  19,  descending  aorta  ;  20,  abdominal  aorta  (cut)  ;  21,  common 
iliac  artery  ;  22,  external  iliac  artery  ;  23,  umbilical  artery,  continuation  of  the 
internal  iliac  artery. 

Fig.  64. — Fetal  heart  and  chief  blood-vessels.  1,  vena  cava  inferior  ;  2, 
Eustachian  valve  ;  3,  foramen  of  Botallo  ;  4,  vena  cava  superior  ;  5,  ventricles  : 
6,  pulmonary  artery  ;  7,  arterial  duct ;  8,  aorta. 


Fig.  63.— Second  fetal  circulation. 


CIRCULATION.  49 

portion  of  the  placenta,  and  combines  with  the  red  blood-corpuscles 
of  the  foetus,  changing  the  hue  of  the  blood  from  a  dark  cherry  color 
to  a  bright  scarlet. 

From  the  capillaries  of  the  placenta  the  rejuvenated  blood  flows 
through  the  umbilical  vein  to  the  umbilicus,  where  it  divides  into  three 
currents,  two  of  which  go  to  the  right  and  left  through  the  venae 
hepaticse  advehentes  to  the  substance  of  the  liver,  while  the  median 
current  continues  in  a  straight  course  through  the  ductus  venosus, 
lying  on  the  lower  surface  of  the  liver,  and  enters  the  vena  cava 
inferior,  which  leads  it  to  the  right  atrium.  Here,  again,  a  separation 
takes  place,  one  portion  going  to  the  right  ventricle  and  another 
through  the  foramen  of  Botallo  to  the  left  atrium  and  thence  to  the 
left  ventricle,  thus  returning  to  the  starting-point. 

The  characteristic  of  the  placental  circulation  is  that  the  two  kinds 
of  blood,  the  arterial  and  the  venous,  are  not  separated.  The  pure 
blood  of  the  umbilical  vein  and  the  ductus  venosus  mixes  with  impure 
blood  coming  through  the  revehent  hepatic  veins  from  the  liver  and 
through  the  omphalomesenteric  vein,  that  gradually  is  transformed  to 
the  portal  vein,  also  from  the  intestine.  At  the  liver  there  is  namely 
a  double  set  of  veins  :  the  vencB  hepaticce  advehentes  bring  pure 
blood  to  the  liver ;  the  vence  hepaticce  revehentes  carry  impure  blood 
away  from  that  organ.  The  former  start  from  the  umbilical  vein  at 
the  lower  end  of  the  venous  duct,  while  the  latter  enter  this  duct  at  its 
upper  end.  Thus,  inside  the  body  of  the  foetus  there  is  unmixed 
arterial  blood  only  on  the  short  distance  from  the  umbilicus  to  the 
anastomosis  between  the  vense  hepaticse  revehentes  and  the  upper 
end  of  the  ductus  venosus. 

As  the  current  progresses,  the  blood  becomes  more  and  more 
mixed.  In  the  vena  cava  inferior  it  comes  together  with  that  return- 
ing from  the  lower  extremities  and  the  pelvic  organs.  In  the  right 
auricle  it  receives  the  blood  coming  from  the  head  and  the  upper  ex- 
tremities, and  in  the  left  auricle  it  is.  joined  by  the  blood  from  the 
lungs.  The  most  impure  blood  is  that  flowing  through  the  veins  of 
the  trunk  and  the  lower  extremities. 

The  head  and  the  upper  extremities  receive  somewhat  better  blood 
than  the  trunk  and  the  lower  extremities,  for,  on  account  of  the 
anatomical  disposition  and  the  direction  of  the  current  of  the  blood, 
most  of  that  coming  through  the  vena  cava  inferior,  and  which  is 
less  impure,  flows  through  the  foramen  ovale,  the  left  auricle,  the  left 
ventricle,  and  the  aorta  to  the  head  and  the  upper  extremities,  while 
the  trunk  and  the  lower  extremities  are  fed  with  the  purely  venous 
blood  from  the  vena  cava  superior  and  a  small  cpantity  of  blood 
from  the  vena  cava  inferior,  which  blood  goes  from  the  right  ven- 
tricle through  the  pulmonary  artery  and  the  ductus  arteriosus,  enter- 

4 


50  NORMAL   PREGNANCY. 

ing  the  aortal  blood  after  the  head  and  the  upper  extremities  have 
been  supplied. 

Third  Circulation. — After  the  first  breath  the  final  circulation,  that 
which  continues  through  life,  has  its  beginning.  The  seat  of  oxygena- 
tion is  now  moved  from  the  placenta,  from  which  the  child  will  soon 
be  separated,  to  the  lungs.  It  is  characterized  by  being  double,  one 
portion  of  the  blood  circulating  between  the  heart  and  the  lungs  and 
another  between  the  heart  and  the  periphery  of  the  body,  and  by  the 
strict  separation  between  arterial  and  venous  blood.  The  foramen 
ovale  closes.  The  ductus  arteriosus  loses  its  lumen  and  forms  a 
short  fibrous  cord  between  the  pulmonary  artery  and  the  arch  of 
the  aorta.  That  portion  of  the  umbilical  arteries  that  lies  between 
the  trunk  of  the  hypogastric  artery  and  the  umbilicus  is  transformed 
into  the  true  lateral  ligaments  of  the  bladder.  The  umbilical  vein 
becomes  the  round  ligament  of  the  liver,  and  the  ductus  venosus  is 
also  obliterated. 

From  the  left  ventricle  the  blood  goes  through  the  aorta  and  its 
branches  to  the  whole  body,  ending  in  capillary  nets,  from  which  the 
blood  enters  the  veins  and  is  poured  into  the  right  auricle  through  the 
venae  cavse  superior  and  inferior.  Hence  it  is  propelled  to  the  right 
ventricle,  thus  completing  the  (jreater  or  systemie  circulation.  Next  the 
dark  venous  blood  flows  through  the  pulmonary  artery  to  the  lungs, 
where  it  is  oxidized  by  absorbing  the  oxygen  of  the  air  which  enters 
through  the  bronchi,  bronchioles,  and  alveoli.  Finally,  the  blood 
returns  as  bright  arterial  blood  through  the  pulmonary  veins  to  the 
left  auricle  and  the  corresponding  ventricle,  from  which  we  started. 
In  this  way  the  lesser  or  pulmonary  circulation  is  finished. 

While  the  transition  from  the  first  to  the  second  circulation  takes 
place  very  gradually,  that  from  the  second  to  the  third  is  in  many 
respects  instantaneous.  At  the  first  breath  drawn  by  the  child  the 
lungs  are  filled  with  air  and  expanded,  so  as  to  attract  a  large  amount 
of  blood.  The  blood  returning  from  the  lung  to  the  left  auricle,  the 
pressure  between  the  two  auricles  is  equalized,  the  current  from  the 
right  auricle  is  stopped,  and  gradually  the  opening  between  the  two  is 
permanently  obliterated. 

The  umbilical  arteries  contract  and  their  walls  grow  thicker  until 
their  lumina  disappear.  The  passage  is  usually  completely  inter- 
rupted at  the  end  of  the  fourth  day.  The  ductus  arteriosus  closes  by 
cell  proliferation  in  its  wall,  and  by  the  end  of  three  weeks  it  is  com- 
pletely impervious.  The  umbilical  vein  and  the  ductus  venosus  col- 
lapse and  are  generally  closed  at  the  end  of  a  week. 


DURATION   OF    PREGNANCY.  51 

CHAPTER   XIII. 

OTHER   FUNCTIONS. 

Besides  circulation,  respiration,  nutrition,  secretion,  and  excretion, 
some  other  functions  are  known  to  take  place  in  the  fetal  organization. 
The  inspissated  condition  of  the  meconium  shows  that  a  resorption 
takes  place  through  the  mucous  memhrane  of  the  intestine.  The  fact 
that  the  meconium  is  always  found  in  the  lowest  part  of  the  intestine 
is  proof  that  this  canal  is  the  seat  of  peristaltic  movement.  By  ap- 
plying our  ear  to  the  abdomen  of  a  woman  during  the  second  half  of 
pregnancy  we  can  hear  the  foetus  move,  and  on  palpating  the  abdo- 
men during  advanced  pregnancy  we  can  both  feel  and  see  the  foetus 
move,  and  the  pregnant  woman  herself  feels  fetal  movements. 


CHAPTER   XIV. 

DURATION    OF   PREGNANCY. 

Both  for  scientific  satisfaction  and  for  the  just  settlement  of  judi- 
cial cases,  it  would  be  desirable  to  know  the  duration  of  gestation  in 
woman,  but,  unfortunately,  this  is  only  possible  mthin  widely  differ- 
ing limits.  In  most  instances  the  date  of  the  fecundating  coition  is 
unknown,  and  even  in  the  comparatively  small  number  of  observations 
of  cases  in  which  only  one  sexual  approach  has  occurred,  we  do  not, 
as  explained  above,  know  when  fecundation — that  is,  the  combination 
of  the  spermatozoid  vnth  the  ovum — was  accomplished.  In  other 
words,  the  true  starting-point  of  gestation  is  unknown.  Furthermore, 
there  cannot  be  any  doubt  that  the  time  from  the  moment  of  fecunda- 
tion till  the  birth  of  the  child  varies  very  much  in  women,  as  it  does 
in  animals.  The  same  woman  fmds  frequently  considerable  diifer- 
ences  in  the  duration  of  her  pregnancies.  Thus,  in  a  case  about 
wiiich  the  writer  has  notes,  in  six  pregnancies  the  tinie  counted  from 
the  first  day  of  the  last  menstruation  was  respectively  two  hundred 
and  seventy-eight,  two  hundred  and  ninety-six,  two  hundred  and 
eighty-two,  two  hundred  and  seventy-two,  two  hundred  and  sixty- 
four,  and  two  hundred  and  seventy-six  days,  and  all  the  children  were 
born  fully  developed.  In  domestic  anmials,  where  impregnation  is 
possible  only  during  rut  and  where  in  most  cases  only  one  coition 
is  allowed,  the  length  of  gestation  varies  very  much :  in  the  horse 
between  two  hundred  and  eighty-seven  and  four  hundred  and  sev- 
enteen days,  in  the  cow  between  two  hundred  and  forty  and  three 
hundred  and  twenty-one  days,  in  the  sheep  between  one  hundred 
and  forty-six  and  one  hundred  and  fifty-eight  days,  in  the  sow  between 


52  NORMAL    PREGNANCY. 

one  hundred  and  nine  and  one  hundred  and  thirty-three  days,  and  in 
the  rabbit  between  twenty-seven  and  thirty-five  days. 

Based  on  large  statistics  the  supposition  is  warranted  that  in  woman 
the  time  varies  between  two  hundred  and  twenty  and  three  liundred 
and  twenty  days,  counting  from  tlie  fecundating  intercourse. 

While  extremes  occur,  the  average  time  from  the  first  day  of  the 
last  menstruation  till  the  birth  of  the  child  may  be  placed  at  two  hundred 
and  eighty  days.  In  animals  the  duration  of  gestation  is  proportionate 
with  their  size,  the  average  being  for  the  elephant  six  hundred  and 
twenty-five,  the  horse  three  hundred  and  forty-five,  the  cow  two  hun- 
dred and  eighty-two,  the  sheep  one  hundred  and  fifty-one,  the  sow 
one  hundred  and  fifteen,  the  dog  sixty,  the  cat  fifty-six,  and  the  rabbit 
thirty-one.  Counting  from  the  prolific  coition  it  would,  of  course,  be 
shorter  in  women  than  two  hundred  and  eighty  days,  and  counting 
from  the  first  missing  menstruation,  which,  as  we  have  seen,  probably 
would  be  more  correct,  it  would  be  still  shorter.  In  taking  the  first 
day  of  the  last  menstruation  as  starting-point,  it  must  be  borne  in 
mind  that  women  not  unfrequently  menstruate  once  or  twice  after 
having  become  impregnated,  but  then  the  amount  of  blood  lost  is 
always  very  much  smaller  than  in  the  unimpregnated  condition.  Gen- 
erally the  practised  hand  of  the  obstetrician  will  also  allow  him  by 
means  of  the  size  of  the  uterus  to  refer  the  beginning  of  the  gestation 
to  the  right  menstruation. 

For  practical  purposes,  it  is  necessary  to  have  some  easy,  method 
of  foretelling  the  expected  day  of  confinement.  Subtracting  280  days, 
the  average  duration  of  pregnancy,  from  365  days,  corresponding  to  a 
calendar  year,  leaves  85  days,  which  should  be  subtracted  from  a 
year,  counting  from  the  first  day  of  the  last  menstruation,  in  order  to 
fimd  the  day  of  expected  confinement ;  but  as  this  would  be  a  trouble- 
some calculation,  it  is  made  much  simpler  by  counting  three  months 
back,  ivhich  would  be  about  92  days,  and  adding  7  days  ;  e.g.,  if  the  first 
day  of  the  last  menstruation  was  the  15th  of  June,  the  expected  day 
of  confinement  is  the  22d  of  March.  But  the  physician  should  take 
care  to  explain  to  the  patient  that  she  may  be  taken  ill  either  earlier 
or  later.  Since  the  whole  calculation  is  so  very  inexact,  it  is  not 
worth  while  to  make  a  difi'erence  for  months  with  thirty  or  thirty-one 
days  nor  special  allowance  for  February  with  twenty-eight  days  or 
bissextile  years  with  three  hundred  and  sixty-six  days. 

The  determination  of  the  shortest  and  longest  possible  duration  of 
gestation  is  of  great  judicial  importance,  and,  unfortunately,  legislation 
has  not  followed  the  accumulated  experience  of  medical  science  in  this 
respect.  The  question  about  the  longest  possible  term  presents  itself 
in  cases  of  the  birth  of  a  child  after  a  husband's  death  or  absence 
from  his  wife.     In  France  and  Germanv  the  law  declares  a  child  ille- 


DURATION    OF   PREGNANCY.  53 

gitimate  if  it  is  born  more  than  three  hundred  days  after  the  last  pos- 
sible connection  between  the  spouses.  In  Austria  three  hundred  and 
seven  days  are  allowed.  In  England  and  America  a  more  liberal  spirit 
prevails,  A  high  authority  on  evidence  (Wharton)  says  :  "  Physicians 
must  determine  the  matter,  and  if  the  space  between  the  minimum 
and  maximum  periods  hitherto  allowed  is  shown  to  be  too  long  or  too 
short,  the  courts  will  readily  follow  the  truth  as  it  is  made  manifest.'" 
In  America  a  period  of  three  hundred  and  thirteen  and  three  hun- 
dred and  seventeen  days  respectively  has  been  judicially  declared 
possDjle.  As  we  have  seen  above,  science  admits  even  the  possibility 
of  a  much  longer  term  of  gestation.  Winckel,  who  has  made  a  special 
study  of  the  c^uestion  as  expert  for  the  court,  places  the  limit  at  320 
days,  and  another  German  scholar,  Schichting,  admits  even  three 
hundred  and  thirty-four  days. 

In  cases  of  protracted  gestation  the  calculation  of  the  woman 
should,  however,  be  confirmed  by  the  unusual  size,  weight,  and  de- 
velopment of  the  child. 

In  other  cases  the  medical  expert  is  questioned  in  regard  to  an 
unusually  short  period  of  gestation.  For  instance,  a  man  has  been 
separated  for  two  years  from  his  wife,  then  they  reunite,  and  at  the 
end  of  seven  months  the  woman  gives  birth  to  a  child.  The  c{uestion 
is,  "Can  it  be  his?"  The  woman's  reputation  and  the  child's  legiti- 
macy are  at  stake.  A  curious  case  of  this  kind  happened  once  in 
high  society.  The  daughter  of  the  house  became  impregnated  by 
a  married  artist,  and  by  the  advice  of  her  mother  she  allured  an 
unmarried  gentleman  to  have  intercourse  with  her,  accused  him  of 
having  ruined  her,  and  demanded  that  he  marry  her. 

In  all  such  cases  the  medical  expert  should  first  carefully  look  for 
all  signs  of  maturity  or  deficient  development ;  but,  even  if  the  child 
is  fully  developed,  he  should  bear  in  mind  that,  just  as  among  animals, 
there  is  great  latitude  in  regard  to  the  time  needed  for  full  develop- 
ment. We  see  the  same  in  childhood ;  one  person  of  fifteen  years 
will  look  as  if  he  were  twenty  years  old,  and  another  as  if  he  were 
twelve.  It  is  painful  to  read  the  testimony  that  has  been  given  in 
court  by  great  obstetricians.  There  is  no  doubt  that  occasionally 
a  seven  or  eight  months'  child  is  born  as  fully  developed  in  every 
respect  as  most  children  are  at  the  end  of  nine  months.  But  there- 
abouts the  limit  must  be  drawn.  In  Germany  the  law  declares  two 
hundred  and  ten  days  to  be  the  shortest  time  of  uterogestation.  Here 
we  are  not  bound  by  any  law,  but  the  lowest  limit  for  full  develop- 
ment cannot  be  placed  much  below  that  mark  in  any  case,  A  foetus 
of  six  months  differs  very  materially  from  one  born  at  the  usual  term. 


54  NORMAL   PREGNANCY. 

CHAPTER    XV. 
DEVELOPMENT    OF   THE  FCETUS   IN    EACH    LUNAR    MONTH. 

In  describing  the  development  of  the  foetus  it  is  convenient  to 
divide  the  average  time  of  two  hundred  and  eighty  days,  or  forty 
weeks,  into  ten  parts,  each  of  four  weeks  ;  but  the  reader  will  bear  in 
mind  the  great  individual  variations  in  regard  to  rapidity  of  develop- 
ment, and  that  the  two  hundred  and  eighty  days  are  counted  from 
the  first  day  of  the  last  menstruation,  while  fecundation  of  the  ovum 
and  the  development  of  the  embryo  begin  later.  In  some  cases  the 
real  age  of  the  embryo  can,  however,  be  ascertained  with  more  or 
less  accuracy. 

First  Month. — The  youngest  human  ova  known  belong  to  the  end 
of  the  first  or  beginning  of  the  second  week.  On  page  29  we  have 
seen  a  reproduction  of  that  described  by  Peters  (Fig.  43),  showing 
the  embryo  in  the  form  of  a  flat  disk  lying  on  the  yolk-sac.  In  the 
youngest  ovum  of  Spee  (Figs.  65,  QQ)  development  has  progressed 
a  little  farther.  The  embryo  is  connected  with  the  chorion  by  means 
of  a  short,  thick  stalk,  called  the  abdominal  stalk,  which  later  is 
developed  to  the  umbilical  cord.  The  primitive  groove  is  visible  and 
the  medullary  tube  is  forming. 

Fig.  67  represents  part  of  the  same  ovum,  showing  that  the  amnion 
was  already  closed.  Fig.  68  shows  a  section  of  the  same  ovum. 
The  allantois  is  growing  into  the  abdominal  stalk.  This  ovum  was 
expelled  one  week  after  the  non-appearance  of  the  expected  menses. 
An  ovum  of  a  slightly  older  date,  but  belonging  to  the  first  half  of 
the  second  week,  is  represented  diagrammatically  in  Figs.  69  and  70. 

In  Fig.  71  is  shown  a  human  ovum  between  12  and  13  days  old. 
It  measures  five  millimetres  in  diameter.  The  chorion  is  covered 
with  villi  and  on  being  opened  reveals  the  embryo  lying  flat  on  the 
large  yolk-sac. 

Fig.  72  represents  a  human  ovum  of  about  14  days. 

The  embryo  represented  in  Fig.  73  ranges  probably  between  the 
two  last  mentioned.  The  slightly  curved  embryo  is  bound  to  the 
chorion  by  the  thick  abdominal  stalk.  On  the  yolk-sac  are  seen 
blood-vessels  belonging  to  the  second  circulatory  system. 

In  the  embryo  represented  in  Fig.  74,  which  is  from  16  to  18 
days  old,  the  amnion  still  hugs  closely  the  embryo.  The  upper 
and  lower  extremities  are  budding  and  the  postoral  arches  have 
appeared. 

Fig.  75  shows  the  development  at  the  end  of  the  third  week.  The 
visceral  arches  are  four  in  number  with  the  clefts  between  thein.  The 
Intesthie  has  become  tubular  and  the  vitello-intestinal  communication 


DEVELOPMExNT  OF   THE   FCETUS   IN    EACH    LUNAR    MONTH. 
Fig.  65.  Fig.  66. 


55 


u.v. 


Human  embrj-o  in  the  second  week,  side 
view  (Spee's  ovum),  am,  amnion;  e,  embrj'o ; 
U.V.,  umbilical  vesicle;  a.s.,  abdominal  stalk 
connecting  embryo  with  chorion  ;  ch,  chorion. 


Human  embryo  in  the  second  week,  seen 
from  above  (Spee's  ovum),  am,  amnion;  md, 
medullary  canal ;  g,  medullary  groove  ;  c.n,  ca- 
nalis  neurentericus ;  pr,  primitive  groove. 


Fig.  67. 


Fig. 


Human  ovum  in  thi'  mcdikI  week.  (Spee.) 
Ch,  chorion;  h,  blood-clot;  am,  amnion;  6, 
a,bdominal  stalk ;  c.e.,  cephalic  end ;  d,  um- 
bilical vesicle. 


Longitudinal  section  of  the  same  human 
ovum  in  the  second  week  (partly  diagram- 
matic), ch,  chorion;  6,  abdominal  stalk;  d, 
umbilical  vesicle  ;  al,  allantois. 

Fig.  70. 


Fig.  69. 


Human  ovum  and  embryo  in  the  second 
week,  a  little  older.  (Spee.)  ch,  chorion  ;  am, 
amnion;  e,  embryo;  a.s.,  abdominal  stalk;  al, 
allantois ;  d,  yolk-sac. 


Longitudinal  section  through  the  saraeovum 
and  embryo.  ch,  chorion ;  ant,  amnion ;  h, 
abdominal  stalk  ;  al,  allantois  ;  e,  embryo :  c.n, 
canalis  neurentericus;  U.,  islands  of  blood  on 
the  wall  of  the  yolk-sac. 


56 


NORMAL    PREGNANCY. 


diminished  in  width.     The  heart  is  S-shaped.     The  rudiments  of  the 
eye  and  ear  are  visible. 


Fig.  71. 


Fig.  72. 


Human  ovum  of  from  12  to  13  days.  (Allen 
Thomson.)  1,  ovum,  natural  size,  chorion  cov- 
ered with  villi ;  2,  the  same  opened  and  mag- 
nified seven  times.  Side  view  of  the  embryo 
lying  flat  upon  the  yolk-sac. 


Human  ovum  and  embryo  of  about  14  days. 
(Allen  Thomson.)  A,  the  ovum  opened,  half 
the  chorion  laid  to  one  side  and  the  embryo  and 
yolk-sac  seen  in  the  other ;  natural  size,  about 
three  times  as  long  as  the  preceding  one. 

B,  the  embryo  and  yolk-sac  viewed  from 
the  dorsal  aspect,  magnified  about  ten  times, 
a,  yolk-sac ;  6,  hind-brain  portion ;  for  a  space 
the  medullary  canal  is  here  closed  ;  c,  the  mid- 
brain open  superiorly ;  d,  hinder  part  of  the 
medullary  canal  also  open ;  e,  portion  of  mem- 
brane, perhaps  belonging  to  the  torn  amnion. 


At  the  end  of  four  weeks  the  yolk-sac  is  pyriform.  The  heart  is 
well  developed.  The  extremities  begin  to  divide  into  proximal  and 
middle  segments  (Fig.  76). 

The  reader  will  remark  how  rapidly  the  development  takes  place 
during  this  month.     At  the  end  of  four  weeks  the  embryo  measures 


Fig.  73. 


Fig.  74. 


tim_. 


7im 


urn- 


Human  embryo  of  less  than  14  days.    (His.)    am, 
amnion  ;  um,  umbilical  vesicle  ;  ch,  chorion. 


Human  embryo  of  10  or  18  days, 
umbilical  vesicle. 


(His.) 


eight  millimetres  in  length  from  the  vertex  to  the  most  prominent 
point  of  the  tail  end,  but  it  is  so  curved  that  the  measurement  taken 


DEVELOPMENT    OF    THE    FCETUS    IN    EACH    LUNAR    MONTH.       57 

along  the  back  is  two  centimetres  (Fig.  77).  The  chorion  is  covered 
with  vilh  all  over.  The  umbilical  vesicle  has  a  narrow  stalk.  The 
amnion  is  spreading  on  the  inside  of  the  chorion.    The  visceral  arches, 


Fig.  76. 


Fig.  75. 


Outline  of  human  embryo  of  fully  three 
"Weeks.  Enlarged  five  times.  (Allen  Thomson.) 
am,  amnion;  uv,  umbilical  vesicle;  al,  allan- 
toic! pedicle ;  ae,  anterior  extremity ;  pe,  pos- 
terior extremity. 


Outline  of  human  embryo  of  about  four 
weeks.  Enlarged  four  times.  (Allen  Thomson.) 
am,  amnion  ;  uv,  umbilical  vesicle  ;  al,  allantoid 
pedicle ;  ae,  anterior  extremity ;  pe,  posterior 
extremity  ;  ?i,  heart.    , 


Fig.  78  shows  the 


the  eye,  and  the  extremities  are  plainly  visible 
unopened  ovum  at  the  end  of  the  first  month. 

Second  Month. — The  embryo  grows  from  8  millimetres  to  2|  cen- 
timetres.    During  the  first  half  it  can  hardly  be  distinguished  from 


Fig.  78. 


Human  ovum  with  embryo  of  four  weeks. 
Natural  size.    (Waldeyer.) 


Human  ovum  at  the  end  of  the  first  month. 
(Wood's  Museum,  Bellevue  Hospital,  No.  1193.) 
Actual  size. 


that  of  an  animal.  The  curvature  from  head  to  tail  diminishes.  The 
abdomen  is  protruding  in  consequence  of  the  growth  of  the  liver. 
The  extremities  show  a  tripartite  division.     The  rudimentary  hands 


58 


NORMAL   PREGNANCY. 


and  feet  appear.  In  the  second  half  of  the  second  month  the  embryo 
acquires  the  form  characteristic  of  the  human  being  and  henceforth  is 
called  frefus.  The  external  nose,  the  external  ear,  and  the  external 
genitals  are  being  formed  (Figs.  79-84).  Fig.  85  shows  the  foetus  and 
ovum  at  the  end  of  the  second  month. 


Fig.  79. 


Semi-diagrammatic  outline  of  an  anteroposterior  section  in  the  median  line  of  a  gravid  uterus 
and  ovum  of  five  weeks.  (Allen  Thomson. j  a,  anterior  wall  of  uterus  with  attached  placenta; 
p,  posterior  wall;  m,  muscular  substance;  u,  uterine  cavity;  v,  decidua  vera,  forming  grooves  and 
prominences  on  its  surface  and  showing  glands  and  blood-vessels  in  its  interior  ;  g  g,  the  basic  part 
of  the  decidua,  containing  the  deepest  part  of  the  glands  ;  s,  decidua  serotina  ;  r,  reflexa ;  ch,  chorion, 
with  villi,  which  are  more  developed  on  the  portion  turned  towards  the  serotina  than  on  that 
covered  \vith  the  reflexa ;  e,  embryo  enclosed  in  tight-fitting  amnion  ;  the  pedunculated  yolk-sac 
with  the  omphalomesenteric  vessels  is  seen  above,  and  the  allantoic  vessels  below,  passing  into  the 
placenta. 


Third  Month. — The  ovum  becomes  as  large  as  a  goose-egg.  The 
foetus  measures  9  centimetres  in  length.  The  intestine  has  with- 
drawn from  the  navel.  In  most  bones  are  found  pomts  of  ossification. 
Fingers  and  toes  with  their  nails  can  be  plainly  distinguished.  The 
external  genitals  begin  to  show  sexual  differences. 

Fourth  Month. — The  foetus  is  from  10  to  17  centimetres  long. 
The  difference  in  the  genitals  of  the  male  and  female  foetus  is  mani- 
fest.    The  intestine  contains  meconium  (Figs.  86  and  87). 

Fifth  Month. — The  f(ptus  is  from  18  to  27  centimetres  in  length. 
The  skin  loses  some  of  its  translucency.     Hair  appears  on  the  head, 


DEVELOPMENT    OF   THE   FOETUS   IN    EACH    LUNAR    MONTH.        59 


Fig.  81. 


Fig.  80. 


Human  embryo  of  second  month,  from  8  Human  embryo  of  nearly  5  weeks.     (His.) 

to  10  millimetres  long.     Enlarged  five  times.       a,  enlarged  five  times ;  6,  natural  size  (11  milL- 
(His.)  metres). 


Fig.  83. 


Human  embryo  of  6 -weeks.    (His.)    a,  enlarged  Human  embryo  about  7  weeks  old.    (His.)    a, 

five  times;  6,  natural  size  (13  millimetres).  enlarged  five  times;    b,   natural    size    (18   milli- 

metres). 


60 


NORMAL   PREGNANCY. 


Fig.  84. 


Embrj'o  about  8  weeks  old.     (His.)    a,  enlarged  five  times ;  b,  natural  size  (23  millimetres). 


Human  ovum  and  fcetus  at  the  end  of  the  second  month.     (Wood's  Museum,  Bellevue  Hospital, 

No.  1197.)    Actual  size. 


DEVELOPMENT    OF   THE   F(ETUS   IN    EACH    LUNAR    MONTH.       61 

and  the  whole  body  is  covered  with  smah  soft  hairs,  cahed  lanugo 
(Fig.  88). 

Sixth  Month. — Length  of  fcetus  from  28  to  34  centimetres.  Adi- 
pose tissue  begins  to  form  under  the  skin,  which  is  full  of  wrinkles. 
The  head  is  still  very  large  in  proportion  to  the  body.     In  the  sixth 


Fig.  86. 


Human  fcetus,  fourth  month.     (Wood's  Museum,  Bellevue  Hospital,  No.  1198.)    Actual  .size. 

month  a  foetus  may  be  born  alive,  gasp,  and  move  the  extremities,  but 
it  dies  invariably  within  a  short  time. 

Seventh  Month. — The  foetus  is  from  35  to  38  centimetres  long.    The 
eyelids  are  separated.     The  body  is  still  lean ;  the  skin  is  red  and 


62 


NORMAL   PREGNANCY. 


Fig.  87. 


Fig. 


Human  fcetus  at  the  end  of  the  fourth  month. 
Actual  size.  (Wood's  Museum,  Bellevue  Hospital, 
No.  1201.) 


->>- 


Human  foetus  of  fifth  month.  Five- 
sixths  of  tlie  actual  size.  (Wood's  Museum, 
Bellevue  Hospital,  No.  1203.) 


VIABILITY.  63 

covered  with  a  yellow,  greasy  substance  called  vernix  caseosa.  Chil- 
dren who  are  the  products  of  a  uterogestation  of  between  twenty-four 
and  twenty-eight  weeks  may  show  lively  movements,  but  the  voice  is 
weak  and  they  nearly  always  die  in  the  course  of  a  few  hours  or  days. 
Since  the  introduction  of  incubators,  several  children  born  between 
the  twenty-seventh  and  the  twenty-ninth  week  and  weighing  only  two 
pounds  or  less  (nine  hundred  and  fifty  grammes)  have  been  reared. 

Eighth  Month. — The  child  acquires  a  length  of  42i  centimetres 
and  a  weight  of  nineteen  hundred  grammes  (nearly  four  pounds). 
The  pupillary  membrane  disappears.  Children  born  in  this  period, 
although  stronger  than  those  of  seven  months,  are  still  apt  to  die  soon. 

Ninth  Month. — The  child  is  46|  centimetres  long  and  weighs  on 
an  average  two  thousand  five  hundred  grammes  (five  pounds).  The 
development  of  adipose  tissue  rounds  out  the  contours  and  obhterates 
wrinkles.  Children  born  between  the  thirty-second  and  the  thirty- 
sixth  week  have  not  the  same  power  of  resistance  as  those  born  at 
full  term,  but  with  proper  care  they  survive,  as  a  rule. 

Tenth  3Ionth. — The  foetus  measures  on  an  average  about  50  centi- 
metres (20  inches)  and  weighs  on  an  average  7f  pounds.  This,  at 
least,  was  the  mean  weight  found  by  Lusk  in  two  hundred  children 
born  in  Bellevue  Hospital,  New  York,  In  different  German  cities  the 
averages  found  were  only  6|,  Q^,  and  6i  pounds.  When  we  compare 
these  weights,  it  must,  however,  be  taken  into  consideration  that  the 
Germans  and  French  by  a  pound  mean  500  grammes,  while  our  avoir- 
dupois pound  weighs  only  453.59  grammes, — nearly  fifty  grammes 
less.  The  weight  found  by  Lusk  equals  three  thousand  four  hundred 
and  seventy-seven  grammes  ;  Leopold  mentions  three  thousand  two 
hundred  as  the  average  weight  in  the  Dresden  clinic.  We  shall,  there- 
fore, not  err  much  by  taking  7  pounds  as  the  general  average. 

During  this  last  month  the  lanugo  disappears  gradually,  but  is  still 
visible,  especially  on  the  shoulders.  The  ends  of  the  nails  do  not  at 
first  reach  the  tips  of  the  fingers.  The  cartilage  of  the  ear  and  nose 
is  soft.  The  skin  is  still  red,  but  smooth.  In  the  latter  part  of  this 
month  the  foetus  develops  all  the  signs  of  a  full-born  child. 


CHAPTER   XV L 
VIABILITY. 


In  certain  lawsuits  the  medical  expert  has  to  testify  on  the  ques- 
tions whether  a  child  was  born  alive  and  whether  or  not  it  was  viable. 
From  the  facts  above  stated  it  appears  that  the  youngest  age  at  which 
a  child  may  be  reared  is  after  a  uterogestation  of  twenty-six  weeks,  or 
one  hundred  and  eighty-two  days.     The  Code  Napoleon  stipulates 


64  XORMAL    PREGXAXCY. 

one  hundred  and  eighty  days  as  the  shortest  limit  within  "which  a 
viable  child  can  be  born,  and  in  France  viability  is  recjuired  in  order 
to  mherit  and  transmit  property.  The  Scotch  law  even  places  the 
limit  at  one  hundred  and  sixty-eight  days,  or  twenty-four  weeks. 


CHAPTER    XYII. 
MATURITY    OF    THE    FCETUS. 

We  have  seen  above  that  the  time  required  for  the  full  develop- 
ment varies  withm  widely  separated  limits.  We  must,  therefore,  look 
for  signs  that  are  indicative  of  a  mature  foetus.  The  new-born  child, 
if  it  is  mature,  has  a  characteristic  general  appearance.  All  its  parts 
are  well  rounded  out  by  an  abundant  mass  of  subcutaneous  achpose 
tissue,  and  it  has  none  of  the  old-man  appearance  so  striking  at  an 
earlier  stage  of  development.  The  color  in  the  Arj'an  race  is  what 
is  commonly  called  white,  but  wliich  is  m  reality  a  mixture  of  pink 
and  pale  yelloAv.  In  the  negro  it  is  somewhat  darker,  especially  on 
the  scrotum  and  the  labia  majora.  The  length  is  about  twenty  inches. 
The  weight  varies  so  greatly  that  it  is  much  less  reliable  than  the 
length.  As  an  average  we  take  about  seven  pounds  (3175  grammes). 
Parents  feel  a  peculiar  pride  in  having  heavy  children,  and  to  please 
them  midwives  exaggerate  the  supposed  weight  of  the  child.  The 
heaviest  baby  that  I  have  delivered  weighed  eleven  and  three-fourths 
pounds,  and  the  heaviest  I  have  seen  in  a  museum  weighed  fifteen 
pounds.  Large  statistics  from  European  lying-in  hospitals  show  a 
decided  influence  of  race  and  locality,  even  in  the  same  people.  The 
size  of  the  parents  has  much  to  do  with  that  of  the  child.  Thus, 
Robert  P.  Harris  states  that  Mrs.  Bates,  a  woman  known  as  the 
Xova  Scotia  giantess,  who  was  seven  feet  nine  inches  high  and  mar- 
ried to  a  man  of  seven  feet  seven  inches,  gave  birth,  in  Ohio,  to  a  child 
weighing  twenty-three  and  three-fourths  pounds  and  having  a  length 
of  thirty  inches.  In  repeated  pregnancies,  up  to  the  seventh,  the 
children  become  larger. 

The  child  is  covered  with  a  considerable  amount  of  vernix  case- 
osa,  a  yellowish,  smeary  substance  found  more  or  less  all  over,  but 
especially  abundant  in  the  armpits  and  the  groms.  It  is  composed 
of  the  secretion  of  the  sebaceous  glands,  epidermis  cells,  and  shed 
lanugo  hairs.  The  scalp  is  covered  with  a  growth  of  hair,  usually  of 
a  dark  color  and  about  an  inch  long.  The  lanugo  has  disappeared 
from  most  of  the  body  and  is  found  only  on  the  shoulders. 

The  navel-string  is  in  the  earlier  months  inserted  comparatively 
near  the  lower  end   of  tlie  bodv.  but  from  the   seventh  or  eighth 


MATURITY    OF    THE    FCETUS. 


65 


Fig.  89. 


month  it  remains  inserted  a  little  below  the  middle  between  the 
ensiform  process  and  the  symphysis  pubis,  the  proportion  being  as 
1  to  1.6.  The  nails  protrude  over  the  tips  of  the  fmgers,  but  on  the 
toes  they  are  a  little  behind.  Their  consistency  is  firm.  Before  the 
end  of  the  seventh  month  the  pupil  is  closed  by  a  fine  membrane 
carrying  blood-vessels,  the  pvpUlary  membrane,  which  thereafter  dis- 
appears. The  cartilages  in  the  nose  and  ears  are  firm,  and  the  outer 
ear  stands  out  separated  from  the  skull.  The  cranial  bones  are  hard 
and  the  sutures  between  them  narrow.  The  circumference  of  the 
thorax,  inclusive  of  the  shoulders,  is  larger  than  the  horizontal  cir- 
cumference of  the  head  at  the  base  of 
the  forehead  (Fig.  89).  The  thorax  is 
larger  than  the  abdomen. 

The  sebaceous  glands,  which  in  earlier 
months  form  comedones  on  the  nose 
and  lips,  are  now  seen  only  on  the  tip 
of  the  nose. 

The  scrotum  is  strongly  wrinkled  and 
contracts  powerfully.  The  testicles  enter 
the  inguinal  canal  in  the  seventh  month, 
arrive  in  the  upper  part  of  the  scrotum 
in  the  eighth,  and  are  found  at  the  bot- 
tom of  the  same  in  the  tenth.  The 
labia  majora,  as  a  rule,  cover  the  labia 
minora. 

The  child  cries  with  a  strong  voice. 
If  a  finger  is  passed  into  its  mouth,  it 
sucks  with  force.  Soon  it  voids  the 
urine  and  the  meconium,  a  tarry,  dark- 
green  or  black  substance  accumulated  in 
the  lower  part  of  the  bowel,  and  composed  of  biliary  pigment,  tauro- 
cholic  and  glycocholic  acids,  cholesterin,  mucus,  horny  epidermal 
scales,  and  down  from  the  skin.  It  does  not  contain  any  albumi- 
noids, the  foetus  having  utilized  them  all  in  the  development  of  ils 
body.  Among  inorganic  substances  the  sulphates  and  chlorides  of 
alkalies  prevail. 

The  child  makes  lively  and  strong  movements  with  its  extremities. 
In  the  lower  epiphysis  of  the  femur  an  ossified  nodule  about  a  quarter 
of  an  inch  in  diameter  is  found  in  most  cases. 

Some  information  as  to  the  maturity  may  even  be  found  in  the 
after-birth ;  the  weight  and  size  of  the  placenta  should  be  noticed,  as 
well  as  the  thickness  of  the  umbilical  cord.  The  presence  of  blood- 
vessels in  the  decidua  outside  of  the  placenta  is  a  sign  of  immaturity. 
After  the  thirty-second  week  scratches  on  the  inside  of  the  amnion 

5 


Horizontal  circunjference  of  the  head. 


QQ  NORMAL    PREGNANCY. 

may  be  seen  with  the  naked  eye  or  at  all  events  with  a  lens.     They 
are  produced  by  the  finger-nails  of  the  foetus. 

Many  circumstances  influence  the  growth  of  the  child.  Thus,  twins 
are,  as  a  rule,  smaller  than  the  average  single  child  and  w^eigh  less. 
Severe  illness  in  the  mother,  especially  syphilis,  retards  development. 


CHAPTER    XV  III. 
OVUM    AND    PLACENTA    AT   TERM. 

At  the  end  of  pregnancy  the  ovum  fills  and  extends  the  uterine 
cavity  and  in  primiparae  even  the  upper  portion  of  the  cervical  canal. 
It  is  composed  of  the  three  membranes — decidua,  chorion,  and 
amnion — and  contains  the  foetus,  wdth  the  umbilical  cord  and  the 
liquor  amnii. 

The  separation  between  the  uterus  and  the  ovum  at  birth  takes 
place  in  the  loose  ampullar  portion  of  the  decidua,  so  that  the  deepest, 
the  basic  part,  remains  in  the  maternal  body.  We  know  from  the 
history  of  development  that,  wdth  the  exception  of  that  part  where 
the  placenta  is  situated,  the  decidua  is  composed  of  two  layers,  the 
decidua  vera  and  the  decidua  reflexa,  but  they  grow^  so  intimately 
together  that  it  is  difficult  or  impossible  to  separate  them  from  each 
other  at  the  end  of  gestation.  On  the  placenta  the  decidua  serotina 
forms  a  thin  gray  layer,  wdiich  follows  all  its  sinuosities  and  may  be 
torn  from  the  underlying  chorion  with  a  thumb-forceps. 

Under  the  decidua  lies  the  chorion,  lightly  attached  to  it,  so  that 
they  are  easily  separated  from  each  other  all  over  the  ovum  outside 
of  the  placenta.  All  the  villi  and  their  vessels  have  disappeared, 
except  at  the  placental  site,  where,  on  the  contrary,  they  have  grown 
so  that  they  form  the  larger  part  of  the  bulk  of  the  placenta. 

Inside  of  the  chorion  and  loosely  attached  to  it  lies  the  amnion, 
a  thin,  transparent,  smooth  membrane.  Its  outer  portion  is  formed 
of  connective  tissue,  a  continuation  of  the  skin  of  the  foetus.  The 
inside  is  formed  of  a  single  layer  of  cuboidal  epithelium,  correspond- 
ing to  the  epidermis  of  the  foetus.  The  amnion  lines  the  whole  ovum 
and  forms  a  sheath  for  the  umbilical  cord.  It  has  neither  nerves  nor 
vessels. 

Between  the  chorion  and  the  amnion  is  found  a  thin  albuminous 
layer  that  does  not  show  any  organization,  and  which  is  a  remnant 
of  the  albuminous  fluid  separating  the  two  membranes  at  an  earlier 
stage.  It  is  called  the  tunica  intermedia  of  Bisehoff,  or  magma  reticule 
of  Velpeau. 

The  LIQUOR  AMNu  fills  the  space  between  the  ovum  and  the  foetus. 


OVUM  AND  PLACENTA  AT  TERM. 


Cu 


It  is  of  a  dirty  yellowish-gray  color,  serous,  turbid,  full  of  small  white 
flocculi,  slightly  alkaline,  and  it  has  the  peculiar,  somewhat  nauseous 
odor  of  the  female  genitals.  It  does  not  coagulate  spontaneously  nor 
on  being  boiled,  but  it  does  so  when  a  drop  of  acetic  acid  neutralizes 
the  alkalinity  of  the  fluid.  The  precipitate  becomes  much  clearer  by 
adding  liquor  potass?e. 

The  microscope  reveals  the  presence  of  oil-globules,  irregular  fat- 
granules,  and  large  flat  cells  containing  fatty  masses  Hke  those  found 
free  in  the  fluid  (Fig.  90).  When  ether  is  poured  on  a  drop  of  the 
fluid,  the  fat  is  drawn  out  of  the  cells,  which  then  look  shrivelled  and 
show  an  irregular  mesh- work  ;  in  some  a  nucleus  is  visible  (Fig.  91). 


Fig.  90. 


Fig.  91. 


Microscopical  elements  in  liquor  amnii. 


Liquor  amnii  cells,  the  fat 
of  which  has  been  drawn  out 
with  ether. 


These  cells  are  changed  fetal  epidermis-cells,  those  of  the  amnion 
being  cuboiclal,  or  short  columnar,  not  flat.^ 

The  liquor  amnii  has  a  specific  gravity  varying  between  1006  and 
1012.  It  contains  nearly  as  much  salts  as  the  serum  of  the  blood, — 
namely,  five  parts  per  thousand.  They  are  phosphate,  sulphate,  and 
carbonate  of  sodium,  phosphate  and  sulphate  of  lime,  and  traces  of 
potassium.  Towards  the  end  of  pregnancy  the  fluid  contains  also  a 
little  urea  (see  p.  45).  Hairs  of  detached  lanugo  are  swimming  in 
it.  It  has  experimentally  been  proved  to  be  a  transudation  partly 
from  the  fetal  and  partly  from  the  maternal  blood,  with  Avhich  fetal 
urine  mixes. 

The  amount  of  liquor  amnii  in  the  mature  ovum  varies  very  much. 
Leaving  out  extremes,  we  may  say  that  it  is  between  one  pint  and 
four  pints. 

The  liquor  amnii  is  useful  in  many  ways,  both  during  the  develop- 
ment of  the  foetus  and  during  labor.     This  fluid  supplies  the  foetus 

^  Garrigues,  Diagnosis  of  Ovarian  Cysts  by  Means  of  the  Examination  of  their 
Contents,  New  York,  1882,  p.  68. 


68 


NORMAL    PREGNANCY. 


with  the  water  necessary  for  its  growth  and  contributes  to  its  nourish- 
ment. In  order  to  be  assimilated  by  the  foetus  the  nutriment  coming 
from  the  mother  must  come  in  contact  with  a  fluid  less  dense  than 
the  maternal  blood  in  which  it  is  dissolved.  The  liquor  amnii  takes 
up  the  urine  occasionally  voided  by  the  fcetus  and  protects  the  foetus 
against  injury.  The  liquor  prevents  parts  of  the  foetus  from  coalescing 
and  favors  the  free  development  of  the  limbs.  It  allows  the  foetus  to 
move  in  the  uterus  and  to  be  placed  in  the  most  favorable  way  for  ex- 
pulsion from  the  same.  It  distributes  evenly  the  pressure  exercised  by 
uterine  contraction,  serves  to  open  the  cervix  and  protect  this  against 
pressure,  and,  finally,  lubricates  and  moistens  the  parturient  canal. 

The  PLACENTA  is  a  circular  mass  or  oval  body,  from  six  to  eight 
inches  in  diameter  and  about  one  inch  thick  in  the  centre,  becoming 

Fig.  92. 


Petal  surface  of  the  placenta. 

thinner  towards  the  periphery.  On  the  fetal  side  (Fig.  92)  it  is  smooth, 
of  a  grayish  color,  and  covered  with  the  amnion,  which,  however,  is 
so  loosely  attached  that  they  may  very  easily  be  separated  from  each 
other.  Under  the  transparent  amnion  are  seen  the  ramifications  of 
the  umbilical  vessels.  On  the  maternal  side  (Fig.  93)  is  the  thin, 
gray  layer  of  decidua,  and  under  that  are  the  dark-red  villi  of  the 
chorion.  This  side  is  uneven,  being  divided  by  deep  furrows  into 
small  roundish  islands  called  cotyledons.  The  decidual  portion  is 
called  the  maternal  placenta,  while  those  parts  belonging  to  the  chorion 
and  amnion  constitute  the  fetal  placenta. 

The  placenta  is,  as  a  rule,  produced  either  on  the  anterior  or  the 


OVUM  AND  PLACENTA  AT  TERM. 


69 


posterior  wall  of  the  uterus  (Fig.  94).  The  upper  end  extends  into 
the  fundus,  while  the  lower  remains  about  four  inches  above  the  in- 
ternal OS.  It  is  situated  a  little  higher  in  primiparae  than  in  those  who 
have  borne  children. 

Fig.  93. 


Maternal  surface  of  the  placenta.    The  decidual  portion  is  called  the  maternal  placenta,  while 
those  parts  belonging  to  the  chorion  and  amnion  constitute  the  fetal  placenta. 

Fig.  94. 


Fig.  95. 


M''' 


,    rU.'- 


Normal  site  and  extension  of  the  placenta 
at  the  end  of  pregnancy.     (Kvistner.) 


Double  placenta. 


If  the  formation  of  the  placenta  begins  at  the  edge  of  the  uterus, 
it  becomes  divided  into  two  halves,  one  on  the  anterior  and  one  on 
the  posterior  wall,  separated  by  a  thin  portion  without  villi  (Fig.  9.")). . 


70 


NORMAL    PREGNANCY. 


The  UMBILICAL  CORD  exteiicls  from  the  abdomen  of  the  foetus  to  the 
placenta.     It  is  about  twenty  mches  long,  the  same  as  the  foetus.     It 


Fig.  96. 


Fig.  97. 


Battledoor  placenta. 


Velamentous  insertion  of  cord= 


is  turned  in  a  spiral  with  more  or  less  windings.  As  a  rule,  it  is 
turned  to  the  left  (seen  from  the  foetus),  more  rarely  in  the  opposite 
direction.  It  is  in  most  cases  inserted  at  or  near  the  centre  of  the 
placenta — central  insertion  (Fig.  92),  sometimes  at  the  margin — mar- 


FiG.  98. 


Fig.  99. 


Diagram  of  origin  of  the  velamentous  inser- 
tion of  the  umbilical  cord.  (Ahlfeld.)  Se)-o<.,de- 
eidua  serotina  ;  Hefi.,  decidua  reflexa  ;  a,  cephalic 
fold  of  amnion ;  a',  caudal  fold  of  amnion ;  t, 
vesicula  umbilicalis  grown  to  chorion. 


Diagram  of  origin  of  velamentous  insertion. 
(Ahlfeld.)  The  umbilical  cord  formed.  Letter- 
ing same  as  in  Fig.  98. 


cjhial  insertion,  or  battledoor  placenta  (Fig.  96),  and  in  rare  cases  on  the 
membranes  at  some  distance  from  the  placenta — velamentous  insertion 


OVUM  AND  PLACENTA  AT  TERM. 


71 


(Fig.  97).  The  velamentous  insertion  is  probably  brought  about  by 
an  adhesion  between  the  yolk-sac  and  the  chorion,  preventing  the 
allantois  from  extending  to  the  serotina.  (See  p.  42  and  Figs.  98, 
99.)  Still  more  rarely  the  umbilical  cord  separates  into  two  branches 
before  reaching  the  placenta— /or/;ecZ  insertion.  The  cord  is  usually  as 
thick  as  an  index-fmger,  sometimes  as  the  little  finger,  and  sometimes 


Fig.  102. 


Fig.  100. 


Transverse  section  of  the  umbilical  cone. 
(Virchow.)  c,  skin  with  blood-vessels;  vm., 
umbilical  vein;  a.u.,  umbilical  arteries;  v.o., 
remnants  of  the  vitelline  duct  and  the  ompha- 
lomesenteric blood-vessels  ;  u.,  remnants  of  the 
allantois  (urachus). 


Fig.  101. 


V.  « 


Transverse  section  of  the  umbilical  cord 
(Virchow.)  a.s.,  amniotic  sheath.  The  other 
letters  same  as  in  Fig.  100 


Capilliaries  at  transition  from  the  umbilical 
cone  to  the  umbilical  cord.  (Virchow.)  A, 
abdominal  wall ;  B,  permanent  portion  of  the 
umbilical  cord,  or  abdominal  umbilicus  ;  C,  ca- 
pillaries at  boundary-lino. 


it  is  as  thick  as  a  thumb  or  even  thicker.  The  thick  cords  are  called 
fat  and  the  thin  ones  lean,  but  the  difference  in  thickness  depends 
chiefly  on  the  larger  or  smaller  amount  of  the  gelatin  of  Wharton. 

The  cord  is  composed  of  two  arteries,  one  vein,  the  epithelial  rem- 
nants of  the  allantois,  the  gelatin  of  Wharton,  and  a  sheath  formed  by 
the  amnion  (Figs.  100,  101).  It  has  no  nerves  or  vessels  of  its  own, 
except  quite  near  the  line  of  demarcation  between  it  and  the  foetus, 


72 


NORMAL    PREGNANCY, 


where  some  capillaries  extend  a  short  distance  on  the  cord  (Fig. 
102).  This  boundary-line  is  c^uite  sharp,  a  little  cone  covered  with 
skin  being  in  contact  with  the  cord,  that  is  covered  with  the  amnion 


Fig.  10.3. 


Fold  of  Sehultze.     PL,  placenta  ;   ['  V.,  umbilical  vesicle  with  vitelline  duct ;  Sch.F.,  fold 

of  Sehultze 

sheath.  At  the  insertion  on  the  placenta  are  found  some  small, 
mostly  flat  epithelial  growths.  The  umbiliccd  vesicle,  the  remnant  of 
the  yolk-sac,  is  not  found  in  the  cord  itself,  but  it  is  found  in  nearly 


Fig.  104. 
3"       5'  '',^^2)>i>^^^'^^'''^ 


_....».j!iii^« 


V^  .>»-W 


Vessels  of  the  umbilical  cord  A,  1,  1',  the  umbilical  arteries  wound  around  the  vein  (2)  ;  3,  3',  ' 
constrictions  corresponding  to  folds  in  the  interior;  4,  4',  crescent-shaped  folds  ;  5,  5',  circular  or  dia- 
phragmatic fold  ;  6,  6',  6",  openings  cut  in  the  wall  of  the  arteries.  B,  1,  the  umbilical  vein  partly 
cut  open ;  2,  constriction ;  3,  3',  3",  crescent-shaped  folds.  C,  transverse  section  of  the  vein  and 
arteries ;  1,  crescent-shaped  fold  in  the  vein  ;  2,  crescent-shaped  fold  in  one  artery  ;  3,  diaphragmatic 
fold  in  the  other  artery 

every  case  at  some  little  distance  from  the  placenta,  between  the 
chorion  and  the  amnion,  adherent  to  the  latter,  or  on  the  placenta 
under  the  amnion.     By  pulling  on  the  cord  a  fold  of  the  amnion  is 


CAUSE   OF    THE    SEX    OF   THE    FCETUS. 


73 


raised  between  the  cord  and  the  placenta,  the  outer  margin  of  which 
is  formed  by  the  remnant  of  the  vitelhne  duct  (Fig.  103). 

The  two  umbihcal  arteries  keep  together  and  are  wound  in  a  spiral 
around  the  single  vein.  Immediately  above 
their  entrance  into  the  placenta  there  is  a 
large  anastomosis  between  the  two,  insuring 
an  even  distribution  of  blood  throughout  the 
placenta.  The  arteries,  as  well  as  the  vein, 
have  semilunar  and  circular  folds,  or  incom- 
plete valves,  marked  outside  by  a  constriction 
of  the  vessel  (Fig.  104).  The  vein  is  much 
more  voluminous  than  both  arteries  together 
(Fig.  101). 

The  remnant  of  the  umbilical  vesicle  is  a 
small  white  body,  about  a  line  long.  From 
it  extends  sometimes  a  fine  thread  in  the  in- 
terior of  the  umbilical  cord,  which  is  the 
upper  part  of  the  same  vesicle,  the  vitelline 
duct,  or  omphalo-enteric  duct.  Sometimes 
even  remnants  of  the  old  omphalomesenteric 
vessels  can  be  distinguished  (Fig.  105). 

The  gelatin  of  Wharton  is  a  continuation 
of  the  connective-tissue  layer  of  the  amnion 
and  the  subcutaneous  connective  tissue  of  the 
foetus.     It  is  a  rather  loose  connective  tissue  mixed  with  elastic  fibres, 
and  serves  to  protect  the  vessels  of  the  cord  against  pressure. 


Remnant  of  the  umbilical 
vesicle  and  om^phalomesen- 
teric  vessels.  (Hartmann.) 
The  large  vessels  are  branches 
of  the  umbilical  artery  and 
vein  in  the  placenta. 


CHAPTER    XIX. 

CAUSE    OF    THE    SEX    OF    THE    F(ETUS. 

Mankind  is  doubly  interested  in  the  question  if  by  any  means  we 
can  produce  one  sex  preferably  to  the  other.  Parents,  as  a  rule,  de- 
sire their  offspring  to  be  of  the  male  sex.  Not  only  are  realms  and 
large  estates  in  many  cases  transmissible  only  to  a  male  heir,  but  even 
those  on  whom  fortune  has  not  lavished  her  sweetest  smiles  think  of 
the  time  when  the  boy  can  make  himself  more  useful  than  a  girl  and 
acquire  independence,  while  his  sister  is  waiting  for  a  husband  to  take 
care  of  her.  On  the  other  hand,  as  agriculturist — and  we  all  ulti- 
mately depend  on  husbandry  for  our  living — man  wants  a  preponder- 
ance of  cows  and  other  female  domestic  animals.  From  olden  times 
he  has,  therefore,  busied  himself  to  find  means  to  accomplisli  his  wish 
to  be  able  to  decide  or,  at  least,  to  influence  the  production  of  the  sex 


74  xN^ORMAL   PREGNANCY. 

wanted  in  the  offspring.  Most  of  the  postulates  in  regard  to  the 
power  of  determining  the  sex  at  wih  are  so  absurd  that  they  are  not 
worth  repeating,  and  even  modern  scientific  men  have  advanced  the- 
ories which  combat  one  another.  Thus  Ploss  thought  that  by  feeding 
the  mother  well  he  could  produce  a  preponderance  of  girls,  while 
Schenck,  the  latest  champion  in  the  field,  teaches  that  the  male  foetus 
has  more  red  blood-corpuscles  than  the  female,  that  the  father  has  no 
influence  in  regard  to  the  formation  of  sex  in  the  offspring,  and  that 
consequently  by  producing  rich  blood  in  the  mother  he  can  force 
nature  to  produce  boys.  It  would,  however,  be  strange  if  the  father, 
from  whom  the  progeny  certainly  can  inherit  the  form  of  the  body,  all 
the  details  that  make  up  a  physiognomy,  personal  peculiarities,  such 
as  the  color  of  the  skin  and  the  hair,  tendencies,  talents,  characteristic 
movements,  diseases,  etc.,  were  not  able  to  exercise  the  slightest  influ- 
ence on  such  a  gross  difference  as  the  sex  of  his  child.  Hofacker  and 
Sadler  contended,  based  on  statistics,  that  the  age  of  the  parents  had 
a  decided  influence,  the  old  male  in  conjunction  with  a  young  female 
being  more  apt  to  procreate  boys  ;  a  theory  that  meets  with  some 
degree  of  countenance  among  agriculturists,  who  always  use  young 
bullocks  to  cover  their  cows.  According  to  Thury,  the  time  of  copu- 
lation has  some  influence  on  the  sex,  copulation  at  the  beginning  of 
the  rut  giving  more  female  calves  and  at  the  end  of  the  rut  more 
male  calves.  This  tlieory  has  in  a  modified  form  been  applied  to 
mankind,  and  many  believe  that  coition  shortly  before  menstruation 
preferably  gives  rise  to  the  birth  of  girls,  and  that  practised  shortly 
after  the  menstrual  period  it  is  more  likely  to  result  in  the  production 
of  boys.  The  experience  of  one  man  goes  for  naught  in  this  ques- 
tion, the  conclusions  drawn  from  even  pretty  large  statistics  from 
lying-in  hospitals  having  been  overthrown  by  examining  still  larger 
numbers. 

As  a  matter  of  fact,  there  are  born  one  hundred  and  six  male 
children  for  every  one  hundred  females,  but,  the  mortality  among  the 
males  being  greater,  this  difference  disappears  at  the  age  of  puberty. 
This  proportion  is,  how^ever,  modified  by  the  age  of  the  mother. 
Thus,  in  Australia,  wdiere,  on  account  of  the  scarcity  of  women,  they 
marry  young,  the  proportion  of  the  boys  to  the  girls  born  is  one  hun- 
dred and  twenty  to  one  hundred.  But,  on  the  other  hand,  statistics  of 
European  countries  show  that  old  primiparge  are  more  apt  to  give 
birth  to  boys  than  to  girls,  even  in  the  proportion  of  from  one  hun- 
dred and  twenty  to  one  hundred  and  forty  boys  to  one  hundred  girls. 

If  an  ovum  contains  more  than  one  foetus,  they  are  invariably  of 
the  same  sex,  which  favors  the  view  that  sex  is  pre-established  in  the 
ovum  itself. 

Some  think  that  originally  all  ova  are  female,  and  only  in  the 


ATTITUDE,    PRESENTATION,   AND    POSITION    OF    THE    FCETUS.      75 

course  of  development  may  acquire  the  male  type.  In  support  of 
this  theory,  attention  is  called  to  the  fact  that  double  monsters,  a  de- 
formity which  can  originate  only  at  a  very  early  stage  of  development, 
nearly  always  belong  to  the  female  sex. 

Experiments  with  ova  of  animals  have  show^n  that,  while,  as  a 
rule,  only  one  spermatozoid  enters  the  ovum,  if  the  ovum  is  weak- 
ened by  contact  with  chloroform,  chloral,  morphine,  nicotine,  and 
other  poisons,  several  spermatozoids  may  penetrate.  Perhaps,  then, 
a  weakened  condition  of  the  mother  in  this  way  may  predispose  to 
the  formation  of  a  male  foetus. 

Statistics  prove  that  great  wars,  in  which  hundreds  of  thousands 
of  men  perish,  have  only  an  evanescent  influence  on  the  proportion 
between  the  sexes,  male  births  following  in  large  preponderance.  The 
explanation  of  this  may  be  that  those  who  are  not  killed  return  sexu- 
ally strong  to  their  wives,  who  in  their  absence  have  been  exposed  to 
privations  which  have  reduced  their  strength.  But  taking  into  con- 
sideration all  these  uncertainties  and  contradictions,  is  it  not  rational 
to  suppose  that  the  matter  is  subject  to  some  regulating  power, 
call  it  God,  Providence,  or  Nature,  who  takes  care  that  the  balance 
necessary  for  the  continuation  of  the  species  is  re-established  ? 


CHAPTER    XX. 
ATTITUDE,   PRESENTATION,   AND    POSITION    OF   THE   FCETUS.      ' 

The  attitude  of  the  foetus  is  the  relation  of  its  different  component 
parts  to  one  another.  Towards  the  end  of  pregnancy  the  head  is 
normally  bent  on  the  thorax,  so  that  the  chin  touches  the  chest. 
The  vertebral  column  is  curved  with  the  concavity  forward.  The  arms 
lie  at  the  side  of  the  thorax  and  the  forearms  are  crossed  in  front  of 
it,  the  wrists  and  fingers  flexed.  The  knees  are  flexed  and  drawn 
up  in  front  of  the  abdomen,  and  the  legs  generally  crossed.  The 
feet  are  bent  up  towards  the  shins.  In  other  words,  the  foetus  is 
pressed  by  the  abdominal  walls,  the  walls  of  the  uterus,  and  the 
ovum  into  the  shape  in  which  it  takes  up  the  least  space  (Fig.  106). 
Partly  the  attitude  is  also  due  to  the  return  of  the  muscles  after  each 
movement  to  the  stage  of  rest.  As  a  rule,  the  umbilical  cord  finds 
room  in  the  space  left  between  the  extremities.  Very  often  it  is, 
however,  wound  around  an  extremity,  the  trunk,  or  the  neck  of  the 
foetus. 

Presentation  is  the  relation  of  the  longitudinal  axis  of  the  fiietus 
to  that  of  the  uterus.  First  of  all  we  must  distinguish  a  longitudinal 
presentation  from  a  transverse  or  cross  'presentation^  because  the  first, 


76 


NORMAL    PREGXANCY. 


generally  speaking,  is  favorable  to  the  expulsion  of  the  foetus  from  the 
maternal  body,  while  the  second,  if  neglected,  gives  rise  to  grave  com- 
phcations,  which  imperil  the  life  of  both  mother  and  child.  The 
longitudinal  presentation  is  that  in  which  the  long  axis  of  the  fetal 
mass  practically  coincides  with  the  long  axis  of  the  uterus.  According 
to  the  pole  of  the  ovoid  formed  by  the  fffitus  which  presents  itself  ah 


Attitude  of  the  fcetus  in  the  uterus. 


the  mouth  of  the  womb,  we  divide  the  longitudinal  presentations  into 
head  jyi'^sentations,  or  cephalic  presentatio)>s,  and  jje/r/c  end  presentations. 
Head  presentations  are  again  subdivided  into  the  vertex  presentation, 
WiQ  face  presentation  (Fig.  107),  and  the  brow  presentation. 

Pelvic  end  presentations  are,  as  a  rule,  breech  presentations  (Fig. 
108),  but  occasionally  one  or  both  knees  may  be  the.  presenting  part 
— knee  presentation  (Fig.  109),  and  still  more  rarely  one  or  both  feet 


ATTITUDE,    PRESENTxVTION,   AND    POSITION    OF    THE    FCETUri.       77 

occupy  the  lowest  part  of  the  uterus — -fool  2Ji'<?f^cntation,  or  footUmj 
presentation  (Fig.  110). 

The  transverse  or  cross  presentation  is  the  one  in  which  the  lon- 
gitudinal axis  of  the  fetal  ovoid  coincides  more  or  less  with  the  trans- 
verse axis  of  the  uterus.  It  is  also  designated  as  shoulder  j)resentation 
(Figs.  Ill,  112),  because  most  frecpently  the  shoulder  sinks  down. 

Frequency  of  Different  Presentations. — For  obvious  reasons,  the  rarer 
presentations,  which  are  likely  to  give  rise  to  complications  and  call 
for  special  skill,  occur  more  frequently  in  institutions  particularly  des- 
tined for  the  treatment  of  labor  cases.     Thus,  the  statistics  of  lying-in 


Fig.  107 


Face  presentation,  left  men  to-anterior  position.     (Tarnier  and  Chantreuil,  1.  c.) 


hospitals  show  that  there  are  about  ninety-five  per  cent,  vertex  pres- 
entations, three  per  cent,  pelvic  presentations,  a  little  over  one-half 
of  one  per  cent,  cross  presentations,  and  about  0.6  of  one  per  cent, 
face  presentations.  But  by  taking  the  statistics  of  a  large  district  in 
Germany  with  ninety-three  thousand  eight  hundred  and  seventy-one 
births,  Spiegelberg  found  97.3  per  cent,  of  vertex  presentations,  0.3 
per  cent,  face  presentations,  1.59  per  cent,  pelvic  presentations,  0.78 
per  cent,  cross  presentations.  It  appears  from  this  that  vertex  pres- 
entations are  so  common  that  all  others  must  be  looked  upon  as 
exceptional.  The  above  figures  represent,  however,  only  the  presen- 
tations at  term.     During  pregnancy  they  change  frequently.     In  the 


78 


NORMAL    PREGNANCY. 


earlier  months  the  uterus  is  more  globular,  there  is  comparatively 
more  liquor  amnii,  and  the  foetus  swims  freely  around  (Fig.  113). 
Later  the  uterine  cavity  becomes  pear-shaped,  a  form  which  does 
not  allow  of  so  free  movements  (Fig.  114).    Uterine  contractions  con- 


FiG.  108. 


c- 

D- 


6     f 
H  - 


%     W^. 


K   1 


Breech  presentation,  left  sacroposrerior  position.  (Waldeyer.)  ^,  the  great  omentum  ;  JS, 
umbilical  cord ;  C,  origin  of  yena  porta ;  Z),  superior  mesenteric  artery  ;  E,  receptaculum  chyli ; 
F,  left  renal  vein  ;  G,  wall  of  the  uterus  ;  H,  placenta.  In  the  accident  which  caused  this  woman's 
death  the  first  sacral  vertebra  was  fractured  and  depressed  in  front  of  the  second. 


tribute  also  to  the  fixation  of  the  foetus.  In  primiparae,  Avhere  the 
uterus  and  the  abdominal  wall  are  of  a  harder  texture  than  in  those 
who  have  borne  children  before,  there  is  less  scope  for  change  of  pres- 
entation.    In  one  hundred  and  fifty  abortion  cases  the  cephahc  pres- 


ATTITUDE,   PRESENTATION,   AND    POSITION    OF    THE    FOETUS.       79 

entation  was  found  only  in  forty-nine  per  cent.,  the  pelvic  in  forty- 
eight,  and  the  transverse  in  three.  In  the  sixth  month  the  head 
presents  itself  already  in  sixty-six  per  cent,  of  cases,  and  after  that  the 
preponderance  of  the  cephalic  presentation  grows  steadily.  In  pluri- 
parse  a  change  of  presentation  is  not  rare,  even  shortly  before  labor. 
In  primiparae,  as  a  rule,  no  change  takes  place  during  the  last  three 
weeks  of  pregnancy.  The  head  is  at  that  time  so  engaged  in  the  pel- 
vis that  a  change  hardly  can  occur.     The  weight  of  the  foetus  has 


Fia.  109. 


Knee  presentation     (Charpentier.) 

some  influence  ;  the  heavier  it  is,  the  less  it  is  likely  to  change  pres- 
entation.    A  narrow  pelvis,  on  the  other  hand,  favors  change. 

Most  frequently  transverse  presentations  are  changed  into  head  pres- 
entations, more  rarely  the  opposite  takes  place.  Breech  presenta- 
tions often  change  into  head  presentations  and  sometimes  the  latter 
are  changed  to  the  former.  Breech  presentations  change  less  fre- 
quently to  cross  presentation  and  vice  versa. 

The  cause  of  this  great  preponderance  of  vertex  presentations  is 
probably  to  be  found  in  the  law  of  gravitation.      If  the  body  of  a 


80 


NORMAL   PREGNANCY. 


new-born  child  tliat  has  died  during  labor  is  immersed  in  a  solution 
of  salt  corresponding  to  its  own  specific  gravity,  it  assumes  a  slanting 
position  with  the  head  and  the  right  side  turned  downward,  which  is 
due  to  the  greater  specific  gravity  of  the  head  and  the  liver.  Another 
theory  is  that  the  fo?tus  moves  by  reflex  movements  until  it  has  found 
the  most  convenient  presentation,  which  is  the  cephalic. 

In  the  erect  position  of  the  woman  the  uterus  rests  on  the  anterior 
abdominal  wall  and  forms  an  anele  of  about  thirtv-five  degrees  with 


Fig.  110. 


Foot  presentation,  right  sacroposterior  position. 

the  horizon.  If  the  back  of  the  foetus  is  turned  forward  its  head  will. 
by  gravitation  alone,  since  it  cannot  escape  backward,  sink  down  on 
the  internal  os.  If  its  back  is  turned  to  one  side,  the  head  will  sink 
to  the  opposite  side.  Since  now  the  back  by  gravity  sinks  forward 
and  to  the  left  in  the  erect  position  of  the  mother,  the  fetal  head 
would  escape  to  the  right. 

When  the  woman  lies  on  her  back  the  uterus  rests  on  the  verte- 
bral column.  The  back  of  the  foetus  avouIcI  sink  downward  and  to  the 
right,  and  the  head  pass  somewhat  to  the  left.  When  the  abdominal 
wall  and  the  uterine  tissue  offer  little  resistance,  the  head  slides,  in- 
deed, a  little  to  one  side  ;  but  wlien  they  are  firmer,  and  if  muscular 


ATTITUDE,   PRESENTATION,   AND    POSITION    OF    THE    FCETUS.      81 

contractions  diminish  the  transverse  diameter  of  the  uterus,  the  head 
is  prevented  from  shding  away,  and  it  remains  on  the  brim  of  the 
jjelvis. 

Again,  when  the  woman  lies  on  her  side,  the  fundus  tips  down  on 
the  same  side  and  the  os  rises  on  the  opposite.  Under  these  circum- 
stances the  head  of  the  foetus,  if  freely  movable,  must  sink  towards 
the  fundus,  and  the  result  will  be  a  pelvic  presentation. 

When  the  foetus  dies,  its  centre  of  gravity  is  moved  farther  down, 
and  it  loses  its  resiliency,  which  explains  why  dead  foetuses  so  often 
are  found  with  pelvic  or  cross  presentation. 

Fig.  111. 


Shoulder  presentation,  head  in  left  side,  dorsoposterior  position. 


Position. — By  the  technical  term  "position  of  the  fa4us"  is  meant 
the  relation  between  certain  points  on  the  presenting  part  of  the 
foetus  to  certain  points  on  the  pelvis  of  the  mother.  In  this  place  we 
consider  only  the  different  positions  connected  with  the  vertex  pres- 
entation. Commonly  the  back  of  the  foetus  is  turned  forward,  and 
much  more  frequently  to  the  left  than  to  the  right ;  exceptionally  it  is 
turned  backward  and  to  the  right,  and  least  frequently  of  all  it  is 
turned  backward  and  to  the  left.  Accordingly  these  positions  have 
been  designated  as  the  fird^  second,  third,  and  fourth  positions  respec- 
tively. Or,  going  by  what  we  feel  in  making  a  vaginal  examination, 
the  first  is  also  called  the  left  oeeipito-anferior  position  (Fig.  106),  the 
second  the  rU/ht  occipito-anterior,  the  third  the  right  occipitoposterior, 

6 


82 


NORMAL    PREGNANCY. 


and  the  fourth  the  left  occipitoposterior  position.  For  convenience 
these  long  names  are  often  reduced  to  their  initials, — L.  O.  A., 
i?.  0.  A.,  li.  0.  P.,  and  L.  O.  P.  positions.  The  point  we  go  by  is 
the  position  of  the  tip  of  the  occipital  bone  (or  the  posterior  fonta- 
nelle)  to  the  iliopectineal  eminence  or  the  sacro-iliac  joint.  If  the  long 
axis  of  the  head  lies  in  a  transverse  direction  in  the  pelvis,  the  tip  of 
the  occipital  bone  corresponds  to  a  point  at  the  brim  of  the  pelvis 
situated  in  the  middle  between  the  iliopectineal  eminence  and  the 
sacro-iliac  joint. 

If,  as  we  have  seen,  the  presentation  is  subject  to  variation  during 
pregnancy,  the  position  is  still  more  liable  to  change  during  both  preg- 

FiG.  112. 


Shoulder  presentation,  head  in  right  side,  dprso-anterior  position. 


nancy  and  labor.  With  the  vertex  presentation  the  left  occipito- 
anterior position  is  by  far  the  most  common  and  the  left  occipito- 
posterior the  least  frequent,  while  authors  disagree  Avidely  in  regard  to 
the  comparative  frequency  of  the  right  occipito-anterior  and  the  right 
occipitoposterior  positions.  If  we  go  by  the  position  in  which  the 
child  is  born,  there  is  no  doubt  about  the  much  greater  frequency  of 
the  right  occipito-anterior  position,  but  in  many  cases  a  rotation  takes 
place  during  labor,  by  which  the  back  is  turned  forward,  so  that  the 
right  occipitoposterior  position  is  changed  into  the  right  occipito- 
anterior position.  According  to  the  statistics  of  Paul  Dubois,  there 
Avere  in  1813  cases  of  vertex  presentation,  left  occipito-anterior  1255, 


ATTITUDE,   PRESENTATION,   AND    POSITION    OF   THE   FCETUS.      83 

right  occipitoposterior   491,  right  occipito-anterior  55,  left   occipito- 
posterior  12. 

The  great  preponderance  of  the  left  occipito-anterior  position  is 
due  to  gravity.     The  uterus  being  inclined  forward,  when  the  woman 

Fig.  113. 


Foetus  in  globular  uterus.    Early  pregnancy.     (Duncan.)    a  b,  axis  of  uterus ;  b  h,  horizontal  line. 

is  in  the  erect  position,  and  the  head  and  back  of  the  foetus,  especially 
its  right  side,  sinking  down,  as  we  have  seen  in  the  above-mentioned 
experiment  of  suspending  the  body  of  a  new-born  child  in  a  salt  solu- 
tion of  its  own  specific  gravity,  by  mere  gravity  the  head  will  go  down 
and  the  back  forward.    The  great  frequency  of  the  left  occipito-anterior 

Fig.  114. 


Effeft  of  gravity  on  foetus  at  end  of  pregnancy.  (Duncan.)  a  b,  parallel  to  axis  of  uterus  and 
pelvic  brim  ;  c  d  e,  perpendicular  line ;  e,  centre  of  gravity  ;  d,  centre  of  flotation  ;  b  h,  horizontal 
line. 

position  is  due  to  the  position  of  the  mother's  rectum,  which  causes  a 
partial  rotation  of  the  uterus,  by  which  its  left  edge  is  carried  a  little 
more  forward  than  its  right  edge.  Thus  the  back  of  the  child  would 
not  only  sink  forward  but  towards  the  left  of  the  uterus. 


84 


NORMAL    PREGNANCY. 


In  the  dorsal  position  of  the  woman,  the  back  of  the  child  would 
by  the  same  process  of  gravity  sink  backward  and  to  tier  right  side, 
which  would  produce  the  right  occipitoposterior  position  and  explain 
why  this  position  is  the  next  in  order  of  frequency  before  labor. 

Another  consideration,  which  may  have  some  influence,  is  that  by 
the  presence  of  the  fecal  matter  in  the  mothers  intestine,  the  left 
oblique  diameter  of  the  pelvis  becomes  shorter  than  the  right,  which 
would  explain  the  tendency  of  the  fetal  head  to  occupy  the  right 
oblique  diameter  with  its  long  axis. 


CHAPTER    XXL 

CHANGES  IN  THE  MOTHER  DURING  PREGNANCY. 

In  virgins  the  uterus  (Fig.  115)  measures  from  2  to  2  J  inches  in 
length,  in  nulliparae  from  2  to  2f  inches,  and  in  multiparse  from  2J 
to  3  inches.     In  virgins  and  nulliparae  the  body  is  only  a  trifle  longer 

Fig.  115. 


Virgin  uterus.  Natural  size.  (Sappey.)  A.  front  view  ;  the  appendages  and  vagina  are  cut  off : 
o.  the  vaginal  portion  of  the  cervix  mth  the  os  externum  ;  h.  isthmus ;  c.  body.  B,  the  same  in  ver- 
tical mesial  section  :  a,  anterior  surface ;  the  letter  is  placed  a  little  above  the  bottom  of  the  vesico- 
uterine pouch.  C  the  same  with  cavity  exposed  by  coronal  section  :  e,  os  externum  ;  rf,  os  internum  ; 
/,  fundus,  the  letter  placed  ju.st  above  the  uterine  opening  of  the  Fallopian  tube. 


than  the  neck,  Avhereas  in  those  who  have  borne  children  it  becomes 
from  three-fifths  to  two-thirds  of  the  length  of  the  whole  organ. 

The  uterus  increases  in  size  in  a  regular  way,  corresponding  to  the 
period  of  pregnancy.  The  woman  should  be  examined  lying  on  her 
back,  for  in  the  erect  position  the  fundus  sinks  forward  and  down- 


CHANGES  IN  THE  MOTHER  DURING  PREGNANCY. 


85 


ward.  The  obstetrician  should  luentany  divide  the  contour  of  the 
abdomen  into  parts,  each  measuring  three  finger-breadths  (about  two 
and  one-lialf  inches),  and  he  wiU  then  lind  the  fundus  at  the  follow- 


^ 


--aSS^- 


Size  of  uterus  at  the  end  of  each  calendar  month  of  pregnancy. 

ing  places  at  the  indicated  periods.  At  the  end  of  the  third  calendar 
month  the  fundus  reaches  the  abdominal  wall  above  the  symphysis ; 
at  the  end  of  the  fourth  it  stands  about  three  finger-breadths  over 
the  symphysis ;  at  the  end  of  the  fifth  as  much  below  the  umbilicus ; 
at  the  end  of  tlie  sixth  as  much  above 
the  umbilicus  ;  at  the  end  of  the  seventh  F^^'-  i^~- 

about  midway    between   the    umbilicus  '^  ^ 

and  the  ensiform  process  ;  at  the  end  of 
the  eighth  month  it  has  again  advanced 
three  finger-breadths.  During  the  first 
half  of  the  ninth  calendar  month  it  rises 
still  and  enters  under  the  edge  of  the 
ribs  and  approaches  the  ensiform  process, 
but  during  the  latter  half  it  sinks  again 
so  as  to  come  back  midway  between 
two  points  marking  the  end  of  the  eighth 
month  and  maximum  height  (Fig.  116). 
Since  these  measures  are  only  approxi- 
mate, there  is  no  necessity  for  using 
lunar  months,  and  since  our  calculation 
of  tlie  period  of  pregnancy  is  based  on  nine  calendar  months,  it  is 
more  practical  to  follow  the  same  system  in  descril^ing  the  size  of  the 
uterus.  The  writer  has  also  found  this  method  very  reliable  in  regard 
to  foretelling  when  confinement  is  to  be  expected. 


uterine  muscle-cells.  Enlargement 
about  twenty,  a,  in  the  unimpreg- 
nated  condition  ;  b,  during  pregnancy. 


86 


NORMAL   TREGNANCY. 


Fig,  118. 


uterus  at  end  of  pregnancy,  m  situ.  (W.  Hunter.)  A  A,  forepart  of  the  chest,  just  below  the 
breasts;  B  B,  the  two  upper  angles  of  the  integuments,  muscles,  and  peritoneum,  turned  back  over 
cartilaginous  margin  of  chest ;  C  C,  the  two  inferior  angles  turned  down  ;  i),  upper  end  of  incision, 
at  ensiform  process  ;  E,  lower  end  of  incision,  at  symphysis  pubis  ;  F,  round  ligament  of  the  liver; 
G  G,  the  epigastric  artery  and  vein,  shining  through  the  peritoneum  ;  //,  the  left  lobe  of  the  liver; 
J,  the  omentum,  spread  over  the  small  intestine  in  the  epigastric  region  ;  A',  the  lower  and  middle 
part  of  the  omentum,  pushed  up  by  the  womb  ;  L,  the  omentum  in  the  right  side,  passing  behind 
that  part  of  the  uterus  from  which  the  right  tube  begins  ;  M,  the  omentum,  left  side,  which  came 
down  in  front  of  the  Fallopian  tube  and  which  \vas  thrown  aside  in  order  that  those  parts  might  be 
seen  ;  NN,  two  turns  of  the  small  intestine ;  O,  the  womb  occupying  all  the  umbilical  and  hypo- 
gastric regions ;  the  fundus  is  tilted  a  little  to  the  right  side  and  the  left  edge  is  canted  forward  ; 
some  parts  of  the  womb  are  more  projecting  than  others,  in  conse(iuence  of  indentations  made  by 
the  intestines  or  of  pressure  exercisi^d  from  witliin  liy  parts  of  the  ftctus;  P,  the  middle  of  the 
placental  site  ;  Q,  a  swelling  corresjionrling  to  tlie  buttocks  of  the  child  ;  RR,  the  round  ligaments 
of  the  uterus ;  >S',S',  the  Fallopian  tubes ;  between  the  round  ligament  and  the  tube  run  the  ovarian 
vessels, — the  small  artery  and  the  large  vein. 


CHANGES  IN  THE  MOTHER  DURING  PREGNANCY. 


87 


When  the  uterus  reaches  the  umbilicus,  this  hollow  becomes  first 
flattened  out  to  a  level  with  the  surroundings,  and  later  it  ibrms  even 
a  protrusion. 

During  the  first  tliree  months  of  pregnancy  the  increase  in  bulk 
is  chiefly  due  to  a  hyperplasia  and  hypertrophy  of  the  muscular  tissue, 
new  muscle-cells  being  formed,  and  the  old  ones  increasing  enor- 
mously in  size,  so  as  to  become  from  seven  to  eleven  times  longer 

Fig.  119. 


The  musculature  of  the  pregnant  uterus,  dissected  and  seen  from  the  side.  (Lusehka.)  ves., 
bladder;  ur.,  ureter;  vag.,  vagina;  port.,  vaginal  portion:  lip  rot,  round  ligament;  Ugov.,  ovarian 
ligament ;  tub.,  Fallopian  tube ;  m.sup.,  superficial  muscular  layer ;  m.vied.,  middle  muscular  layer. 


and  from  two  to  five  times  wider  (Fig.  117)  than  before.  Later  the 
increase  in  size  of  the  uterus  is  brought  about  by  the  growth  of  the 
ovum,  which  expands  the  uterine  cavity.  At  term  the  uterine  wall 
measures  only  from  five  to  ten  millimetres  in  thickness.  Tlie  chief 
growth  takes  place  in  the  fundus.  This  portion  of  the  uterus,  whicli 
in  the  unimpregnated  state  forms  only  a  slightly  convex  line  (Fig.  115), 
is  at  the  end  of  pregnancy  elevated  into  a  high  cupola  (Fig.  118). 
The  cervix  is  displaced  upward  and  backward,  and  the  angle  between 


88  NORMAL   PREGNANCY. 

it  and  the  body  of  the  womb  becomes  smaller,  the  result  being  a 
physiological  anteflexion. 

In  the  latter  part  of  pregnancy  the  uterus  is  tilted  over  to  the 
right,  so  that  the  greater  part  of  it  lies  in  the  right  side  of  the  body, 
and  besides,  the  left  edge  is  canted  forward,  displacements  which 
probably  are  due  to  the  descending  colon  being  more  filled  with  fecal 
matter  than  the  ascending. 

The  muscular  tissue  may  be  separated  into  three  layers.  The 
outer  layer  is  thin  and  continuous  with  the  musculature  of  the  tubes, 

Fig.  120. 


2gs^''?jjs?f^ 


The  musculature  of  the  pregnant  uterus,  front  view.  (H61ie. )  The  peritoneum  has  been  dis- 
sected off  and  the  bladder  separated  from  the  uterus  and  turned  do-vvn.  1 1,  the  Fallopian  tubes ; 
itgr.r.,  the  round  ligaments;  ves.,  the  bladder. 

the  round  ligament,  and  the  ovarian  ligament.  It  forms  a  hood  over 
the  fundus,  but  leaves  the  side  edges  free  (Figs.  119  and  120.)  The 
innermost  layer  forms  concentric  rings  around  the  openings  of  the 
tubes,  and  others  encircling  the  uterus  (Fig.  121).  The  middle  layer 
is  composed  of  bundles  crossing  one  another  in  all  directions,  often 
forming  bows,  returning  in  the  direction  they  came  from,  and  de- 
scending between  the  bladder  and  the  vagina  (Figs.  119  and  120). 
In  the  lowest  part  of  the  body  of  the  uterus — the  so-called  lower 
uterine   segment — the    muscle    bundles    are  arranged   in    flat  layers 


CHANGES   IN    THE   MOTHER   DURING    PREGNANCY. 


S9 


which  go  slanting  inward  and  downward  from  the  peritoneal  coat  to 
the  decidua.  These  being  held  together  with  short  lamellae  extend- 
ing from  one  to  the  other,  there  remain  between  them  rhomboid 
hollows  (Figs.  122,   123,  124). 

The  wall  of  the  uterus  becomes  remarkably  soft,  so  that  even  in- 
testinal knuckles  can  make  dents  in  it  and  prominent  portions  of  the 
foetus  form  protuberances  on  the  surface  (Fig.  118). 

The  cervix  also  softens  and  increases  in  length  and  circumference, 
but  no  new  muscle  tissue  is  formed  within  it.     There  seems  to  be  a 


Ftg.  121. 


The  submucous  muscular  layer  of  the  pregnant  uterus.     (Hclie.) 

shortening  of  the  cervix  when  it  is  palpated  from  the  vagina,  which 
is  due  partly  to  the  sAvelling  of  the  vaginal  wall,  partly  to  the  softness 
of  the  cervix,  and  partly — in  priniiparae — to  the  descent  of  ilie  liead 
into  the  cervical  canal  towards  the  end  of  pregnancy.  The  glands  of 
the  cervix  secrete  a  thick  mucus,  which  fills  the  ceiAical  canal  like 
a  plug  and  closes  the  uterine  cavity.  (Compare  Superfetation  and 
Infection.) 

Not  only  the  musculature,  but  all  the  component  parts  of  the  uterus 
and  the  neighboring  organs  grow.  The  arteries  Jbrm  long  spirals,  the 
veins  are  dilated  to  large  flat  spaces,  called  siiii(.<<es  (Fig.  125). 


90 


NORMAL   PREGNANCY. 


The  ovarian  blood-vessels  are  nearly  as  large  as  the  uterine  (Fig. 
126).  The  lymph-vessels  are  enlarged,  the  nerves  swell,  and  the 
large  cervical  ganglion  increases  much  in  size  (Fig.  127).  The  weight 
of  the  uterus,  which  in  the  virgin  is  about  an  ounce,  reaches  two 
pounds.  The  capacity  of  the  cavity  is  five  hundred  and  nineteen 
times  greater. 

In  growing  the  uterus  separates  the  two  layers  of  the  broad  liga- 
ments and  lifts  them  up.  The  round  ligament  is  enlarged.  The  peri- 
toneum is  lifted  up  from  the  bottom  of  the  pelvic  cavity  to  a  level 
with  the  posterior  jDart  of  the  iliopectineal  line. 


Fig.  122.       Fig.  123. 


Fig.  12-4. 


Fig.  122.— Longitudinal  section  through  the  lower  segment  of  a  pregnant  uterus.     (Ruge. ) 
Fig.  123. — The  same  section,  in  which  the  muscular  lamellse  have  been  pulled  apart,  showing 

the  rhomboid  cavities  between  them. 

Fig.  124. — A  similar  section  of  a  puerperal  uterus,  showing  the  shortening  of  the  musculature 

after  birth.     O.I.,  internal  os  ;  C.R.,  contraction  ring. 


The  ureter  adhering  to  the  peritoneum  follows  an  entirely  different 
course  from  that  found  in  the  unimpregnated  state.  Its  middle  part, 
that  which  in  the  unimpregnated  condition  sinks  down  to  the  spine 
of  the  ischium,  is  during  pregnancy  lifted  up  to  the  brim  of  the  pelvis. 
From  the  point  where  the  ureter  crosses  the  iliac  arteries  it  goes  for- 
ward, downward,  and  outw^ard,  lying  immediately  under  the  peri- 
toneum, on  the  wall  of  the  false  pelvis.  A  little  behind  the  ends  of 
the  transverse  diameter  of  the  brim  of  the  pelvis  it  dips  into  the  true 
pelvis  and  goes  in  a  curved  line,  inward,  forward,  and  downward,  till 
it  reaches  the  bladder.     In  this  way  it  passes  under  the  broad  liga- 


CHANGES  IN  THE  MOTHER  DURING  PREGNANCY. 


91 


nient,  and  in  front  of  this  it  lies  again  immediately  under  the  peri- 
toneum. From  the  point  where  it  opens  into  the  bladder  to  the  pos- 
terior surface  of  the  pubes,  behind  the  spine,  is  a  distance  of  three 

Fig.  125. 


^\'omb  with  fcetus  of  a  primlpara  at  the  end  of  pregnancy,  vertex  presentation,  right  occipito- 
anterior position.  (W.  Hunter.)  The  upper  part  of  the  bladder  has  been  cut  away  in  order  to  show 
the  head  in  the  lower  part  of  the  uterus.  The  forepart  of  the  womb  and  the  membranes,  which 
included  the  placenta,  have  been  removed.  The  cut  surface  of  the  uterine  wall  shows  large  venous 
sinuses  injected  with  wax. 


inches.  It  will  thus  be  seen  that,  while  the  posterior  part  of  the 
pelvic  portion  of  the  ureter  is  lifted  to  so  high  a  level,  the  anterior  end 
retains  its  position  (Fig.  128). 

Tlie  tubes  follow  an  almost  perpendicular  course  on  the  side  of 
the  uterus  (Fig.  118).  Their  musculature  grows,  they  are  softened, 
and  sometimes  even  decidual  tissue  is  formed  in  parts  of  their  mucous 
membrane. 


92 


NORMAL    PREGNANCY. 


The  ovaries  are  draAvn  up  into  the  abdommal  cavity  so  as  to  lie 
about  midway  between  the  level  of  the  fundus  and  that  of  the  ex- 
ternal OS  (Fig.  118).  As  we  have  seen  above,  the  one  corpus  luteum 
that  corresponds  to  the  pregnancy  remains  to  the  end,  but  no  new 
ones  are  formed  while  it  lasts. 

The  vagina  becomes  softer  and  larger,  its  anterior  wall  often  bulg- 
ing through  the  entrance  (Fig.  129).     It  has  a  characteristic  purple 


Fig.  V2(\ 


a^^/fi 


ei^/urn^ 


a.  urrvM.  ^  /Y 


I^T^'V^'^ 


The  blood-vessels  of  the  uterus  at  the  end  of  pregnancy. 


color.  Its  adipose  tissue  is  absorbed.  The  riilca  becomes  darker, 
softer,  and  swollen. 

The  iliosacral  joint  and  the  symjjhysis  i^ubis  become  softer,  larger, 
and  allow  a  greater  mobility,  by  which  the  passage  of  the  foetus 
through  the  pelvic  canal  is  facilitated. 

The  breads  are  the  seat  of  important  changes.  Small  glands  in 
the  areola,  called  3Iontgoineri/'s  glands,  and  similar  in  structure  to  the 
mammary  gland,  become  enlarged  and  form  a  more  or  less  complete 
circle  around  the  nipple.     Small  pigmented  tongues  shoot  out  in  the 


Fk;.  1211. —Vulva  aiKt  protrudiug  anterior  wall  ol  vagina  in  primiirraviila. 


CHANGES    IX    THE    MOTHER    DURING    PREGXAXCY. 


9^ 


circumference  of  the  areola,  beginning  upward  and  outward.  Each 
two  of  these  tongues  blend  by  their  tops,  leaving  a  small  round  circle 
of  unpigmented  skin  between,  which  by  contrast  with  the  pigmented 
appears  as  a  white  spot.  New  tongues  are  formed  outside  of  the 
first  ring  until  the  radius  of  the  areola  becomes  two  or  three  times  as 

Fig.  127. 


The  nerves  of  a  pregnant  uterus.  (Frankenhiiuser.)  Pl.hijp.,  hypogastrii'  j>k-xus;  2  nerr.tt., 
3  7(.s.,  4  n.H.,  second,  third,  and  fourth  sacral  nerves;  Or.,  ovary;  tuh.,  Fallopian  tube;  Uc;.,  round 
ligament ;  vo,  ovarian  vein. 


long  as  it  was  before.  This  extension  of  the  areola  is  called  the 
secondary  areola.  Its  color  differs,  corresponding  to  tlie  color  of  the 
individuaFs  hair  and  skin.  In  blondes  it  is  light  brown,  in  brunettes 
dark  brown  (Figs.  130-133).  The  true  areola  becomes  swollen,  the 
nipple  more  prominent  and  covered  with  small  scales  formed  by 
inspissated  secretion.     By  pressure  on  the  breast  a  drop  of  clear  fluid 


94 


NORMAL   PREGNANCY. 


may  sometimes  be  made  to  appear  on  the  top  of  the  nipple.  The 
whole  breast  becomes  larger  and  heavier  so  that  it  hangs  down.  The 
veins  become  more  visible.  Strice^  like  those  on  the  abdomen,  are 
often  seen  radiating  from  the  areola. 

The  mammary  gland  undergoes  a  great  development  in  order  to 
prepare  it  for  the  rec{uirements  of  lactation.  Until  the  age  of  puberty 
this  gland  remains  little  developed.  Each  acinus  is  composed  of  a 
few  end  bulbs  sprouting  from  a  lactiferous  duct  (Fig.  134).  But  at 
puberty  the  glandular  structure  becomes  more  complicated  (Fig.  135). 

Fig.  128. 


^PlKIW**^'^ 


The  course  of  thu  ureters  at  the  end  of  pregnancy.     (Polk.) 


During  pregnancy  new-formed  adipose  tissue  is  interspersed  between 
the  acini.  The  lactiferous  ducts  from  one  lobule  of  the  manmiary 
gland  anastomose,  and  form  finally  a  single  duct  which  perforates 
the  nipple  separately.  At  the  base  of  the  nipple  each  forms  a  spindle- 
shaped  dilatation,  called  a  lactiferous  sinus  (Fig.  136). 

The  woman  often  experiences  shooting  pains  through  tlie  breasts. 
In  the  face,  especially  the  forehead,  appear  often  large  brown  spots, 
called  chloasmata  uterina.  In  the  median  line  of  the  abdomen  a  similar 
pigmentation  commonly  takes  place,  extending  as  a  dark  line  upward 
from  the  symphysis  pubis  to  the  umbilicus  or  even  to  the  processus 


Fig.  130.— Breast  of  unimpregnated  blonde. 


<&i 


3 


Fig.  131.— Breast  of  pregnant  blonde. 


^ 


V      .  <■ - 


Fig.  132.— Breast  of  unimpregnated  brunette. 


'*      M 


^%     ■  > 


Ftg.  133. — Brea.'it  of  pjreprnant  hniiK'tte. 


CHANGES    IN    THE    MOTHER    DURING    PREGNANCY. 


95 


Fig.  134. 


ensiformis.     As  a  sign   of   pregnancy  this  so-called  linea  fusca 

little  value.     Sometimes   it  is  missing  in  pregnancy  ;  and  often 

pecially  in  brunettes,  it  is  found  in 

unimpregnated  women.    Around  the 

umbilicus  it  widens  sometimes  to  a 

circle    which    has    been    called    the 

umbilical  areola. 

In  consequence  of  the  great  dis- 
tention of  the  abdominal  wall,  the 
corium  gives  way  in  many  places, 
much  like  an  old  elastic  stocking. 
Thus  the  so-called  strim  (Fig.  137) 
are  formed.  They  have  a  purplish 
color.  After  childbirth  they  shrink 
and  become  white,  with  a  silvery 
shining  surface  and  fine  transverse 
wrinkles,  and  are  then  called  since 
albicantes.  Like  the  linea  fusca  they 
have  little  value  as  signs  of  preg- 
nancy, for  they  are  not  always  formed  during  pregnancy  and 
may  be  due  to  other  causes.     Thus,  the  writer  knows  a  man 


has 
es- 


Acinus  of  the  mammary  gland  of 
sixteen  years  old.     (Langer.) 


a  girl 

they 
who 


Fig.  135. 


Acini  of  a  mammary  gland  of  a  girl  of  eighteen  years.     { I,iinger. ) 


has  them  on  his  arms.     Having  given  much  attciifion  to  athletic  sport, 
the  powerful  contractions  of  his  biceps  muscles  have  had  the  same 


96 


NORMAL   PREGNANCY. 


effect  on  the  skin  of  his  arms  as  the  gradual  distention  of  the  uterus 
and  mammary  gland  has  on  the  skin  of  the  abdomen  and  breast  in 
pregnant  women. 


Fig.  136. 


Mammary  gland  of  a  woman  during  lactation  with  lactiferous  ducts  and  sinuses.     (Luschka.) 

New  adipose  tissue  is  formed  under  the  skin,  especially  at  the  hips. 
The  centre  of  gravity  moves  farther  back.  The  uterus  tipping  forward 
against  the  anterior  abdominal  wall  in  the  erect  posture,  the  woman 
is  obliged  to  carry  her  body  backward  in  order  not  to  fall.     This 

peculiar  attitude  together  with  the  mo- 
bility of  the  pel  vie' joints  gives  a  pregnant 
woman  a  peculiar  gait. 

The  lungs  are  pressed  up  by  the 
rising  fundus,  but  what  they  lose  in 
height  they  gain  in  width,  so  that  their 
capacity  remains  unclianged. 

The  dull  area  of  the  heart  is  in- 
creased, in  consecfuence  of  a  hypertro- 
phy of  the  left  ventricle,  which  has  an 
increase  of  work  to  perform. 

The  intestine  and  the  omentum  are 
pushed  upward  and  to  the  sides  (Fig. 
118). 

The  lower  extremities  commonly  become  adematous  and  their 
veins,  as  well  as  those  of  the  labia  majora,  often  show  varicosities, 
changes  which  are  referable  to  the  pressure  of  the  uterus  on  the  large 
venous  trunks  in  the  pelvis  and  the  abdomen. 


Colostrum. 


(L.  Fischer.) 


Fig.  137.— AlKloiniiial  stri». 


CHANGES   IN    THE    MOTHER   DURING   PREGNANCY.  97 

On  the  inside  of  the  cranium,  especiahy  on  the  parietal  and  frontal 
bones,  flat  osteophytes  are  frequently  formed. 

In  the  beginning  of  pregnancy  frequent  micturition  is  a  common 
symptom ;  later  there  may,  on  the  contrary,  be  retention  of  urine, 
the  urethra  becoming  compressed.  The  urine  sometimes  contains 
sugar  and  not  unfrequently  small  amounts  of  albumin,  but  such 
glycosuria  and  albuminuria  are  on  the  border-line  of  a  pathological 
condition.  Constipation  is  quite  common.  The  vaginal  and  vulvar 
secretion  is  increased,  and  some  degree  of  leucorrhoea  is  frequent. 
Sometimes  the  secretion  of  sahva  is  increased.  In  the  breasts  is 
formed  a  secretion  called  colostrum  (Fig.  138).  Examined  under  the 
microscope  it  shows  colostrum-corpuscles,  large  globular  cells  contain- 
ing fat-globules.  During  pregnancy  it  is  a  colorless  serous  fluid,  but 
after  the  birth  of  the  child  it  has  a  yellow  color,  is  richer  in  albu- 
minoids than  milk,  and  has  an  aperient  effect  on  the  child. 

The  thyroid  gland  also  swells  during  pregnancy,  but  returns  later 
to  its  normal  dimensions,  unless  the  patient  suffers  from  goitre. 

Menstruation  ceases.  Sometimes  there  may  once  or  twice  be  a 
recurrence,  but  then  the  amount  of  blood  lost  is  much  smaller  than 
usual. 

The  composition  of  the  hlood  changes.  The  total  quantity  is 
increased,  and  it  contains  more  water,  fibrin,  and  white  blood-cor- 
puscles and  less  haemoglobin. 

The  nervous  system  is  in  a  state  of  excitement.  Often  the  woman 
€omplains  of  headache,  backache,  toothache,  or  pleurodynia.  Often 
she  has  a  pronounced  desire  for  certain  things, — so-called  longings, — 
or  a  marked  aversion  for  others.  The  mental  condition  varies  much 
according  to  circumstances.  Thanks  to  antiseptic  midwifery  the  times 
are  no  longer  when  a  woman  knew  she  ran  a  considerable  risk  of 
her  life  in  giving  birth  to  a  child.  Still,  from  childhood  she  has 
been  taught,  "In  sorrow  thou  shall  bring  forth  children."  Married 
primiparae  are,  however,  as  a  rule,  happy  at  the  thought  that  they  are 
destined  to  go  through  the  last  stage  of  physiological  development 
characteristic  of  their  sex ;  that  they  shall  call  one  of  these  sweet 
little  babies,  whom  by  instinct  all  women  love,  their  own,  and  that 
it  will  be  a  new  tie  between  them  and  their  husbands.  How  different 
is  the  position  of  the  poor  unmarried  girl  who  feels  that  she  is  going 
to  be  a  mother !  Her  social  position  is  lost,  perhaps  she  is  disowned 
and  cursed  by  her  nearest  relatives,  and  perhaps  poverty  stares  her  in 
the  face.  No  wonder,  then,  that  she  is  apt  to  be  downcast,  melan- 
choly, full  of  apprehension,  a  condition  of  mind  that  has  a  decided 
bearing  on  the  prognosis  in  regard  to  mortality  and  morbidity  in  child- 
birth. Finally,  we  have  the  married  multipara  who  has  already  found 
it  hard  to  make  both  ends  meet,  and  who  deplores  an  addition  to 

7 


98  NORMAL   PREGNANCY. 

her  family.  Upon  the  whole,  most  women  approach  then'  confine- 
ment with  a  serious  turn  of  mind,  wliich  in  some  amounts  to  appre- 
hension and  dread,  sometimes  mixed  Avitli  despair.  The  humblest 
woman  who  is  going  to  give  birth  to  a  child  should,  therefore,  inspire 
her  accoucheur  with  genuine  sympathy.  His  knowledge  and  skill, 
however  great  they  may  be,  do  not  suffice ;  he  must  feel  with  his 
patient,  pity  her  sufferings,  think  of  her  dangers,  forgive  her  sins, 
comfort  and  encourage  her,  and  not  forget  that  she  is  going  to  give 
birth  to  a  human  being,  perhaps  one  of  Nature's  favorites,  maybe  one 
who  will  become  a  benefactor  of  mankind.  The  French  proverb  is 
right :  '^  Femme  enceinte,  femme  sainte''  (a  pregnant  woman  is  a  holy 
woman). 


CHAPTER    XXII. 
THE    UTERUS    AT    THE    END    OF    PREGNANCY. 

Sections  through  the  median  line  of  frozen  bodies  of  women  who 
died  at  the  end  of  pregnancy  or  during  labor  have  afforded  a  valuable 
complement  to  the  classical  work  of  William  Hunter,  "The  Anatomy 
of  the  Human  Gravid  Uterus,"  of  which  we  have  reproduced  two 
plates  above  (Figs.  118,  uterus  at  term  in  situ,  and  125,  uterus  and 
fffitus  at  the  end  of  pregnancy).  In  Fig.  108  we  have  given  a  repro- 
duction of  one  of  these  sections  in  a  case  of  pelvic  presentation. 
Fig.  139  shows  a  vertex  presentation  in  a  case  of  narrow  pelvis. 

In  the  dorsal  position  of  the  woman  and  when  there  is  no  muscu- 
lar contraction,  the  uterus  rests  on  the  spinal  column,  and  on  account 
of  its  softness  it  moulds  itself  on  it  to  some  extent.  The  intestine 
and  the  liver  press  on  it  from  alDove,  and  prominent  portions  of  the 
foetus  make'it  bulge  out.  As  a  whole  it  forms  a  lengthy,  irregular  bag. 
The  cut  surface  of  the  uterine  wall  shows  the  large,  flat  venous 
sinuses. 

The  fundus  is  on  a  level  with  the  second  lumbar  vertebra  or  even 
the  cartilage  between  it  and  the  first.  In  primiparaj  the  resistance  of 
the  abdominal  wall  brings  it  nearer  to  the  vertebral  column  ;  in  multi- 
parse  the  fundus  sinks  more  forward  and  downward  to  the  umbilicus. 
Compared  with  the  condition  found- in  the  third  and  fourth  months 
the  wall  is  thin,  quite  exceptionally  reaching  one  centimetre  (seven- 
sixteenths  of  an  inch)  in  some  places. 

During  the  last  few  weeks  of  pregnancy  the  lower  part  of  the 
body  of  the  uterus  widens.  In  pluriparae  the  cervical  canal  retains 
its  full  length  (from  1^  to  1|  inches),  while  in  primiparae  the  upper 
part  of  it  is  expanded  and  merges  in  the  cavity  of  the  body. 


THE  UTERUS  AT  THE  END  OF  PREGNANCY. 


99 


In  pluriparae  the  uterus  remains  above  the  pelvic  brim ;  in  primi- 
parse  it  is  pushed  deep  down  into  the  pelvis  by  the  pressure  from  above. 

Fig.  139. 


Longitudinal  section  through  the  body  of  a  woman  at  the  end  of  pregnancy.  Vertex  presenta- 
tion, right  occipito-anterior  position  ;  narrow  pelvis ;  prolapse  of  an  arm.  (Braune.)  -•!,  duodenum ; 
B,  pancreas;  C,  stomach;  I>,  uterus;  E,  pubic  bone;  F,  bladder;  G.  glans  clitoridis ;  //,  vena  cava 
inferior  ;  1,  vena  jx)rta3 ;  .7,  j)leura  ;  K,  right  renal  vein  ;  L.  right  common  iliac  artery  ;  M,  rectum  ; 
-iV.  vaginal  portion  ;  0,  levator  ani  muscle  ;  P,  vagina  ;  Q,  external  sphincter  ani  muscle  ;  R,  rectum; 
S,  internal  sphincter  ani  muscle  ;  T,  internal  sphincter  ani  muscle  ;  V,  e.xternal  sphincter  ani  muscle. 

During  nearly  the  whole  period  of  pregnancy  the  uterus  contracts 
from  time  to  time.    These  contractions  may  help  to  prevent  stagnation 


100  NORMAL    PREGNANCY. 

of  blood  in  the  uterine  veins.  They  are  also  instrumental  in  deter- 
mining the  presentation  of  the  foetus,  and  towards  the  end  of  pregnancy 
they  serve  to  expand  the  lower  uterine  segment  and  open  up  the  upper 
part  of  the  cervical  canal  in  primiparse.  They  are,  as  a  rule,  not  per- 
ceived by  the  pregnant  woman  and  are  not  accompanied  by  pain,  if 
the  organs  are  in  a  healthy  condition. 


CHAPTER    XXIII. 
SIGNS   OF   PREGNANCY. 

All  the  changes  in  the  mother  described  above  are,  of  course, 
signs  of  pregnancy,  but  since  many  of  them  are  common  in  other 
conditions  and  some  are  hardly  available,  it  is  of  practical  importance, 
even  at  the  risk  of  seeming  to  repeat  what  has  already  been  said,  to 
pass  these  changes  in  review  from  the  stand-point  of  their  value  in 
guiding  the  physician  in  determining  the  question  frequently  put  to 
him,  whether  a  woman  is  pregnant  or  not. 

There  are  only  very  few  sure  signs  of  pregnancy — a  single  one  of 
which  suffices  for  a  diagnosis, — namely,  to  hear  the  fetal  heart  or  the 
sound  sometimes  produced  in  the  umbilical  cord,  to  feel,  see,  or  hear 
the  movements  of  the  foetus,  to  feel  parts  of  the  fetal  body,  and  to 
feel  uterine  contractions. 

The  fetal  heart  somid  is  a  double  sound  produced  by  the  contrac- 
tion of  the  auricles  and  ventricles  of  the  fetal  heart.  It  may  be  heard 
from  about  the  middle  of  pregnancy.  It  is  in  most  cases  easily  dis- 
tinguished from  that  of  the  mother  by  being  about  twice  as  frequent 
and  of  smaller  volume ;  but  if  the  maternal  pulse  beats  rapidly  the 
frequency  alone  would  not  suffice  to  recognize  the  fetal  heart  sound, 
smce  what  we  hear  might  be  the  maternal  heart  sounds  weakened 
by  being  heard  at  so  great  a  distance.  Any  doubt  in  this  respect  is, 
however,  easily  cleared  up  by  following  the  sound  up  to  the  region 
where  the  maternal  heart  is  situated,  when  we  find  the  sounds  gradu- 
ally increasing  in  strength.  In  most  cases  the  distinction  is  also  easily 
made  by  holding  the  index-fmger  on  the  mother's  wrist  while  we  listen 
to  the  fetal  heart.  Any  pulsation  due  to  the  maternal  cu'culation  is 
synchronous  with  the  contraction  of  the  ventricles  of  the  maternal 
heart  and  radial  pulse,  and  the  accompanying  sound  is  single.  The 
character  of  the  sound  is  peculiar.  It  has  iDeen  likened  to  the  ticking 
of  a  watch,  and  this  gives  also  a  good  idea  of  the  double  sound ;  but  on 
the  other  hand,  the  fetal  heart  has  not  the  hard  metallic  ring  perceived 
by  applying  a  watch  to  the  ear.  The  fetal  heart  sound  is  heard  on 
the  anterior  wall  of  the  abdomen,  which  for  the  purpose,  with  due 


SIGNS    OF    PREGNANCY.  101 

regard  to  cleanliness  and  decency,  should  be  covered  with  a  thin  cloth, 
for  instance  a  fine  pocket-handkerchief,  unless  a  stethoscope  is  used. 
In  the  most  common  presentation  and  position  of  the  foetus — the  left 
occipito-anterior  position  in  the  vertex  presentation — the  sound  is 
heard  most  distinctly  about  two  inches  below  and  to  the  left  of  the 
umbilicus,  being  transmitted  in  the  shortest  line  from  the  heart  through 
the  back  of  the  child  to  the  abdominal  wall.  But  often  it  may  be 
heard  over  a  large  area.  In  the  right  occipito-anterior  position,  the 
sound  is  often  heard  most  distinctly  farther  out  to  the  side,  being  con- 
ducted through  the  thorax  of  the  foetus.  In  pelvic  presentations  the 
heart  sound  is  heard  a  little  above  the  umbilicus.  Thus  the  situation 
of  the  place  where  the  sound  is  perceived  most  distinctly  gives  even 
some  information  as  to  the  presentation  and  the  position  of  the  foetus. 
Furthermore  the  frequency  of  the  fetal  heart  contractions  sometimes 
gives  at  least  a  hint  in  regard  to  the  sex  of  the  foetus.  The  nearer 
the  contractions  come  to  120  per  minute,  the  surer  the  foetus  is  a 
male,  and  the  nearer  they  come  to  144,  the  greater  is  the  likelihood 
that  it  is  a  female  ;  but  most  frequently  it  is  132  or  thereabout,  which 
does  not  allow  the  accoucheur  even  to  make  an  intelligent  guess.  In 
the  writer's  experience  the  frequency  of  the  heart  sound  is  a  pretty 
reliable  guide  in  foretelling  the  sex,  if  the  frequency  is  either  decidedly 
slow  or  rapid. 

The  heart  sound  varies  much  in  frequency  in  consequence  of  the 
condition  of  the  foetus.  The  mere  presence  of  a  stethoscope  increases 
its  frequency.  It  becomes  also  more  frequent  in  febrile  diseases  of 
the  mother.  On  the  other  hand,  it  becomes  much  slower  towards 
the  end  of  fetal  life,  and  may  thus  furnish  indications  for  the  inter- 
vention of  the  accoucheur.  AVhen  the  foetus  dies,  the  heart  sound 
stops  altogether,  but  the  mere  fact  that  it  cannot  be  heard  signifies  by 
no  means  that  the  foetus  is  dead.  The  silence  may  be  due  to  a 
change  of  position  or  other  circumstances.  One  day  the  sound  may 
not  be  audible,  and  the  next  we  hear  it  again. 

The  umbilical-cord  sound  is  a  single  or  double  blowing  sound  syn- 
chronous with  the  first  fetal  heart  sound.  It  is  rather  rare,  and  is 
probably  due  to  compression  or  tension  of  the  cord.  In  some  cases 
in  which  this  sound  is  audible  the  cord  may  be  felt  through  the  anterior 
abdominal  wall  crossing  over  the  back  of  the  foetus. 

The  sounds  produced  by  the  feted  movements  are  very  character- 
istic. Sometimes  the  sound  denotes  a  soft,  sliding  movement,  and  at 
other  times  it  is  like  a  smart  slap  against  the  ear  applied  to  the  ab- 
dominal wall  or  against  the  end  of  the  stethoscope.  Such  sounds 
may  be  heard  as  early  as  the  end  of  the  third  month  of  pregnancy. 
They  are  mostly  produced  by  movements  of  the  extremities  of  the 
foetus,  but  some  are  attributed  to  hiccough.     We  can  also  feel  these 


102  NORMAL    PREGXAXCY. 

movements  when  we  place  the  hand  on  the  abdomen  :  and  often  they 
are  so  marked  that  they  are  easily  seen. 

A  practised  hand  can  in  most  cases  of  advanced  pregnancy  easily 
distrnguish  characteristic  parts  of  thefcetus. — the  round  hard  head,  the 
long  cylindrical  back,  the  rounchsh  but  softer  breech,  the  large  and 
long  thighs,  the  hard  and  pointed  knees,  and  beyond  them  the  shorter 
and  thinner  legs  and  feet. 

From  the  time  the  pregnant  uterus  reaches  tlie  alDdominal  wall 
we  may  by  seizing  it  with  the  hand  and  holding  it,  feel  it  harden  in 
consequence  of  muscular  contraction.  If  the  phenomenon  does  not 
appear  readily,  it  is  well  to  dip  the  hand  in  ice-cold  water  before 
applying  it  to  the  uterus.  Xo  tumor  or  swelling  of  any  other  kind 
possessing  the  power  of  contraction,  it  is  an  absolutely  sure  sign  of 
pregnancy,  and  may  be  perceived  even  after  the  death  of  the  fcetus. 

The  diagnosis  of  pregnancy  is  most  ditficult  in  the  beginning, 
nearly  all  the  certain  signs  being  limited  to  the  second  half  of  preg- 
nancy. The  first  sign  to  appear  is  the  cessation  of  menstruation.  If 
in  a  woman  who  has  always  had  her  courses  regularly  and  who  has 
been  exposed  to  become  impregnated  the  menstrual  flow  does  not 
appear  at  the  time  it  is  expected,  there  is  prima  facie  great  proba- 
bility that  she  is  pregnant ;  but  the  sign  is  far  from  reliable.  The 
suppression  of  the  menses  may  be  due  to  exposure  to  wind  and 
weather,  a  refrigeration  of  the  feet,  aneemia,  tuberculosis,  or  other 
diseased  conditions.  After  an  abortion,  or  after  the  inside  of  the 
womb  has  been  curetted,  or  after  a  severe  haematemesis,  sometimes 
several  months  pass  before  the  period  is  re-established.  It  is  not 
rare  that  in  newly  married  women,  in  consequence  of  the  excitement 
of  the  new  relations,  menstruation  is  interrupted.  It  happens  also 
in  unmarried  women  who  have  had  sexual  intercourse  and  dread  the 
consequences. 

Impregnation  may  take  place  in  women  who  have  never  men- 
struated, either  because  they  have  not  reached  puberty,  or  because 
that  function  never  becomes  established  in  them.  It  occurs  also 
frequently  during  that  suppression  of  the  menses  which  is  due  to 
lactation. 

If  to  the  absence  of  menstruation  are  added  nausea  and  vomiting, 
the  probability  increases.  The  so-called  morning  sicJcness — nausea 
experienced  before  breakfast — is  particularly  suspicious.  If  a  woman 
vomits  and  can  eat  a  meal  immediately  thereafter,  disease  of  the 
stomach  and  functional  disturbance  of  the  mtestinal  tract  due  to  other 
causes  may  be  excluded,  and  there  is  the  greatest  likelihood  of  her 
being  pregnant.  The  morning  sickness  is  probably  sympathetic, 
brought  about  by  pressure  on  the  uterine  nerves  by  the  expansion  of 
the  womb. 


SIGNS    OF    PREGNANCY.  103 

Among  the  objective  signs,  the  two  earliest  in  the  writer's  experi- 
ence are  the  above  described  changes  in  the  breasts  and  the  softening 
of  the  lower  uterine  segment.  By  means  of  the  development  of 
Montgomery's  glands  and  small  brown  tongues  shooting  out  from  the 
outer  and  upper  circumference  of  the  areola,  he  has  often  recognized 
the  existence  of  pregnancy  in  primiparae  as  early  as  six  weeks  since 
the  beginning  of  the  last  menstruation.  In  women  Avho  have  borne 
children  this  sign  is  of  much  less  value,  and  at  all  events  it  develops 
later. 

About  the  same  time  appears  another  sign  of  great  value, — the 
softening  of  the  loicer  uterine  segment,  after  its  discoverer  called  Hegar's 
sign.  It  is  not  necessary,  as  recommended,  to  carry  this  test  to  such 
extremes  as  to  compress  the  whole  lower  uterine  segment  between 
the  hard  cervix  and  the  upper  part  of  the  body  of  the  uterus,  which 
manipulation  is  probably  not  without  danger  to  the  woman.  All  that 
is  needed  is  to  feel  just  above  the  cervix,  near  the  median  line,  a 
point  not  larger  than  the  tip  of  the  finger,  where  the  tissue  is  so  soft 
that  the  finger  sinks  in  as  if  pressed  into  butter.  If  the  uterus  is 
retroflexed,  the  soft  point  is  felt  on  the  corresponding  part  of  the 
posterior  surface. 

Braun-FernwalcVs  Sign. — Another  early  sign  of  pregnancy  that 
often  is  present  is  a  difference  in  the  shape  of  the  two  lateral  halves 
of  the  uterus,  the  side  where  the  ovum  is  situated  being  thicker  in  an 
anteroposterior  direction.  On  the  anterior  surface  is  commonly 
found  a  vertical  groove  separating  the  two  unequal  parts. 

The  presence  of  a.  fluid  in  the  breasts  is  less  reliable  than  the  pig- 
mentation of  the  skin  and  the  development  of  Montgomery's  glands. 
It  has  been  found  accompanying  uterine  and  ovarian  tumors,  and  the 
writer  has  seen  it  in  a  virgin,  following  the  injection  into  the  uterine 
cavity  of  diluted  licjuor  ferri  chloridi  for  hemorrhage  produced  by  a 
fibroid.  On  the  other  hand,  the  cessation  of  milk  secretion  during 
lactation  is  often  a  sign  denoting  that  a  new  pregnancy  has  com- 
menced. The  change  of  color  of  the  vagina  is  also  often  observed  at 
an  early  date  of  pregnancy. 

The  increase  in  the  size  of  the  v?omh  is  likewise  characteristic.  First 
the  anteroposterior  diameter  lengthens,  so  that  the  uterine  body  be- 
comes more  globular  in  contradistinction  to  the  cylindrical  cervix. 
Next  the  uterus  becomes  broader,  its  edges  moving  nearer  to  the 
walls  of  the  pelvis.  Last  of  all  the  height  is  increased.  At  the  same 
time  that  the  body  is  enlarged,  we  feel  it  more  anteflexed.  often  resting 
close  on  the  whole  anterior  wall  of  the  vagina. 

Softening  of  the  cervix,  if  well  developed,  has  some  value  as  a  sign 
of  pregnancy.  The  cervix  of  the  unimpregnated  uterus  feels  like  the 
lip  of  the  nose  ;  that  of  the  impregnated,  like  the  lips  of  the  mouth. 


104  NORMAL   PREGNANCY. 

But  oedema,  especially  of  the  anterior  lip,  is  not  rare  in  gynaecological 
patients  outside  of  pregnancy.  In  the  lower  part  of  the  side  edges, 
especially  on  the  left  side,  is  heard  a  single  blowing  sound  like  the 
one  we  hear  on  the  side  of  the  neck  of  chlorotic  women.  It  is 
called  the  uterine  souffle  or  bruit.  From  its  locality  we  may  conclude 
that  it  is  produced  in  the  large  uterine  vessels.  It  is  synchronous 
with  the  maternal  pulse.  It  can  be  heard  from  the  time  the  uterus 
rises  into  the  abdominal  cavity  to  the  end  of  pregnancy,  and  is  not 
affected  by  the  death  of  the  foetus.  Since  a  similar  sound  may  be 
produced  by  uterine  or  ovarian  tumors,  it  is  not  a  reliable  sign  of 
pregnancy,  but  taken  together  with  other  early  signs  it  has  its  value 
as  corroborative  evidence. 

The  enlargement  and  softness  of  the  vagina  with  increase  of  the 
secretion  of  that  organ  deserve  consideration.  The  sensation  of  pul- 
sation in  the  vaginal  roof  is  quite  common  outside  of  pregnancy. 

The  lineafiisca  is  of  little  importance.  In  some  pregnant  women 
it  is  little  developed ;  and,  especially  in  brunettes,  it  may  be  found  in 
virgins,  extending  even  to  the  ensiform  process. 

Purple-colored  strice  may  denote  pregnancy,  but  may  also  be  pro- 
duced by  tumors  distending  the  abdominal  wall. 

Ballottement  is  by  some  regarded  as  a  certain  sign  of  pregnancy. 
The  word  is  taken  in  two  different  meanings.  In  the  wider  accepta- 
tion it  means  the  perception  of  the  displacement  of  a  thin  fluid  in  pal- 
pating the  foetus  through  the  abdominal  wall.  In  the  narrower  sense 
it  applies  to  vaginal  examination.  The  woman  is  placed  in  a  half- 
sitting  posture.  One  or  two  fingers  are  introduced  to  the  roof  of  the 
vagina,  and  the  uterus  is  steadied  by  the  other  hand.  By  suddenly 
pushing  the  vaginal  finger  upward,  we  displace  the  whole  foetus,  which 
floats  up  in  the  liquor  amnii  and  shortly  thereafter  sinks  down  again 
on  the  tip  of  the  examining  fingers.  This  may  be  observed  between 
the  fourth  and  the  seventh  month.  Before  that  time  the  foetus  is  too 
freely  movable  to  sink  down,  and  later  it  is  too  large  to  be  displaced. 
Ballottement  is  a  valuable  sign  of  pregnancy,  but  subserous  fibrous 
tumors  of  the  uterus  or  a  cancerous  tumor  of  the  omentum,  accom- 
panied by  ascites,  may  give  a  sensation  resembling  it  pretty  closely. 

Sometimes  distinct  fluctuation  can  be  made  out  by  a  bimanual  ex- 
amination similar  to  that  just  described,  even  at  an  earlier  date  than 
ballottement,  indeed  from  the  end  of  the  second  month. 

Fetal  movements  felt  by  the  mother  are  of  little  value,  as  they  often 
appear  so  late  that  the  certain  signs  are  already  developed,  and  often 
are  supposed  to  be  felt  by  women  who  wish  or  dread  to  be  pregnant, 
although  they  are  not  in  that  condition.  Still  more  worthless  are, 
of  course,  all  sorts  of  pains  and  aches,  longings  and  other  mental 
changes.     The  first  perception  of  fetal  movement  by  the  mother — the 


DIFFERENTIAL   DIAGNOSIS   OF    PREGNANCY.  105 

so-called  quickening — occurs  most  frequently  about  the  middle  of  preg- 
nancy, but  while  some  women  experience  the  sensation  at  the  end  of 
three  months,  others  do  not  have  it  before  two-thirds  of  the  time  is 
gone.  The  character  of  the  movements  also  varies  much.  While 
they  sometimes  cause  a  rather  pleasant  sensation,  at  other  times  they 
may  be  so  strong  as  to  be  inconvenient  or  even  painful  and  disturb 
the  woman's  sleep. 

Some  women  assert  that  they  can  feel  when  conception  takes 
place.  What  they  feel  is  probably  the  entrance  of  seminal  fluid  into 
the  uterus,  but  insemination,  as  we  have  seen  above,  does  not  neces- 
sarily lead  to  impregnation. 


CHAPTER    XXIV. 
DIFFERENTIAL   DIAGNOSIS    OF    PREGNANCY. 

In  early  pregnancy  the  enlargement  of  the  uterus  may  be  due  to 
subinvolution  after  the  previous  pregnancy  or  to  chronic  laetritis.  As 
a  rule,  however,  there  will  in  these  cases  be  a  history  of  suffering 
which  does  not  correspond  to  pregnancy.  There  may  be  a  congestion, 
especially  when  the  uterus  is  retroflexed,  a  displacement  that  is  apt  to 
interfere  with  the  free  circulation  in  that  organ.  If  menstruation  con- 
tinues, pregnancy  may  be  excluded.  Myonm  of  the  uterus  may  be 
taken  for  pregnancy,  but  this  disease  is  not  accompanied  by  cessation 
of  menstruation,  and  often  it  causes,  on  the  contrary,  menorrhagia  or 
metrorrhagia, — i.e.,  hemorrhages  at  the  time  of  the  menstrual  period 
or  in  the  interval  between  the  regular  discharges.  The  cervix  is  apt 
to  be  merged  with  the  corpus  at  a  much  earlier  date  than  in  the  preg- 
nant uterus. 

Most  commonly  an  ovarian  cyst  is  taken  for  pregnancy  or  vice  versa, 
but  ovarian  cysts  have  not  that  regular  development  which  is  so  char- 
acteristic of  pregnancy.  As  a  rule,  menstruation  continues.  The 
tumor  develops  in  one  side,  and  not  in  the  middle,  as  does  the  preg- 
nant uterus.  Ovarian  cysts,  as  a  rule,  cause  pain,  especially  the  der- 
moid variety.  They  show  much  more  distinct  fluctuation.  Presence 
of  contraction  decides  that  the  swelling  is  the  pregnant  uterus.  By 
anaesthetizing  the  patient  and  pulling  the  cervix  down  Avith  a  volsella, 
the  whole  unenlarged  uterus  may  be  palpated  with  two  fingers  in  the 
rectum  (Hegar's  method). 

Ascites  is  due  to  some  disease,  especially  of  the  heart,  the  liver,  or 
the  kidney.  The  abdomen  is  much  flatter  and  softer.  The  dull  per- 
cussion area  changes  according  to  the  position,  the  fluid  gravitating  to 
the  lower  parts  of  the  abdominal  cavity.  Fluctuation  is  exceedingly 
distinct. 


106 


NORMAL    PREGNANCY. 


If  there  is  a  transverse  partition  closing  the  vagina  or  the  cervix, 
the  menstrual  blood  accumulates,  forming  a  uterine  tumor  which  miq-ht 


Fig.  140. 


Hysterical  tympanites.     (Spencer  Wells.) 
Fig.  141. 


The  same  patient  when  anfesthetized.     (Spencer  Wells.) 


be  mistaken  for  the  pregnant  uterus;  but  in  these  cases  there  are 
painful  molimina  at  the  time  the  fluid  should  appear.  The  cervix 
disappears  sooner  than  m  pregnancy,  while,  on  the  other  hand,  the 
body  grows  much  more  slowly. 


PHYSICAL    EXAMINATION.  107 

Simple  development  of  adipose  tissue  is  often  taken  for  pregnancy, 
alttioLigh  these  conditions  are  easily  differentiated  by  the  history  of 
the  case  and  by  the  absence  of  all  signs  of  pregnancy  except  the  large 
abdomen.  By  bimanual  examination,  if  not  from  the  vagina,  then 
from  the  rectum,  the  small  uterus  is  felt. 

When  pregnancy  is  combined  with  ascites  or  a  uterine  or  an  ovarian 
tumor,  one  of  the  two  may  easily  be  overlooked  if  the  obstetrician 
does  not  think  of  the  possibility  of  the  complication,  and  even  if  he 
does  so  the  diagnosis  may  be  difficult ;  but  by  careful  examination,  if 
necessary  under  anaesthesia,  the  condition  will  be  cleared  up. 

Pseudocyesis,  or  spurious  pi^egnancy^  is  a  curious  imitation  of  preg- 
nancy found  in  nervous  or  hysterical  women  who  are  anxious  to  have 
offspring,  either  in  the  beginning  of  married  life  or  at  the  approach  of 
the  menopause.  Menstruation  ceases,  the  abdomen  increases  in  size 
(Fig.  140),  a  tumor  can  be  felt,  percussion  may  even  be  dull  on  account 
of  contraction  of  the  abdominal  muscles,  the  areolae  change,  and  the 
patient  believes  that  she  feels  fetal  movements.  In  due  time  labor 
pains  set  in.  The  patient,  her  friends,  and  sometimes  her  physician, 
too,  think  she  is  pregnant  or  even  in  labor.  Specialists  have  been 
sent  for  to  perform  embryotomy  or  Csesarean  section.  And  still  it  is 
all  only  a  simulacrum  of  pregnancy  brought  about  by  the  working  of 
the  mind  on  the  nervous  system.  Accurate  physical  examination  will 
show  the  absence  of  all  the  certain  signs  of  pregnancy,  and  if  the 
patient  is  anaesthetized,  the  distended  abdomen  flattens  out  and  the 
unimpregnated  uterus  may  be  palpated  (Fig.  141).  When  the  patient 
recovers  consciousness  the  apparent  swelling  is  reproduced.  A  simi- 
lar condition  is  said  to  be  found  in  domestic  animals.  In  the  case 
from  which  the  figures  are  taken  which  accompany  the  description 
no  suspicion  of  pregnancy  was  entertained,  but  the  patient  and  her 
friends  thought  she  had  an  ovarian  tumor.  In  cases  of  supravaginal 
hypertrophy  of  the  cervix  the  obstetrician  should  be  particularly  on  his 
guard  not  to  overlook  a  complication  with  pregnancy.  The  cervix, 
being  as  long  as  the  whole  normal  uterus  and  sometimes  thickened, 
is  taken  for  the  entire  organ.  The  error  is  best  avoided  by  following 
the  lateral  edges  of  the  cervix  upward  till  they  join  the  corpus. 


CHAPTER    XXV. 
PHYSICAL    EXAMINATION. 

In  making  a  physical  examination  of  an  obstetrical  case  we  employ 
inspection,  external  palpation,  percussion,  auscultation,  vaginal  exami- 
nation, and  rarely  a  speculum. 

If  the  examination  is  made  in  the  physician's  office  or  a  dispensary 


108  NORMAL    PREGXAN'CY. 

before  labor  lias  begun,  it  is  best  to  place  the  patient  on  one  of  the 
usual  gynaecological  examination-tables. — for  instance,  Daggett's  (Fig. 
142).  She  should  beforehand  loosen  all  bands  around  her  waist  and 
remove  her  corset.  If  she  has  closed  drawers,  she  should  slip  off  one 
side  of  them.  If  they  are  open,  it  is  enough  to  push  them  down  to 
the  symphysis  pubis.     She  should  be  placed  in  dorsal  position  (Fig. 

143).  on  a  thin  horse-hair  mattress 

Fig   142  ' 
■       ■                         covering  the  level  table,  and  with  a 

^^m,__^,.„_  cushion  under  her  head.    The  heels 

^te^gf^^^^^^^^^.  of  her  shoes  should  be  placed  in  the 

^^^^^^^^^^^^^^^^^^  openings  in  the  extensions  serving 

^^^^^^^^^^^^^^  as  stirrups.     She  should  at  first  be 

a    ^  a  ^  covered  with  a  sheet  up  to  the  waist, 

H     |i  11  11  but  when   the  examination  begins, 

s^^^=ff,^^g^g|Lf  the  sheet  is  pushed  down  to  the  sym- 

^P*^~r^^~^^^^^^  physis   together  with  the  drawers, 

^^  should  be  pushed  up  towards  the 

Daggett's  examination-table.  ,  ,  ,  n  i     i 

breasts  so  as  to  expose  the  whole 
abdomen  to  view.  By  inspection  we  notice  the  size  and  shape  of  the 
abdomen,  and  if  the  size  is  unusual,  we  take  the  measure  of  the  cir- 
cumference of  the  body  on  a  level  with  the  umbilicus  with  a  tape 
measure.  We  look  for  linea  fusca  and  strise,  purple  and  white,  the 
condition  of  the  umbilicus,  and  fetal  movements. 

Next  we  proceed  to  the  palpation  of  the  abdomen.  Most  authors 
recommend  that  this  be  done  with  the  hands  laid  flat  on  the  abdomen 
and  the  fingers  turned  up  to  the  chest  of  the  woman.  The  writer 
finds,  however,  that  we  have  a  much  finer  perception  by  turning  the 
tips  of  the  fingers  against  the  object  Ave  wish  to  feel,  and  he  places 
himself,  therefore,  at  the  right  side  of  the  patient  and  turns  the  fingers 
downward  against  the  fundus  uteri  (Fig.  144)  or  transversely  over  the 
abdomen  in  palpating  the  body  of  the  foetus  (Fig.  145). 

The  consistency  of  the  uterus  is  tense  and  elastic,  but  there  is  felt 
through  the  abdominal  wall  no  fluctuation,  unless  there  is  an  abnor- 
mal quantity  of  liquor  amnii.  The  fundus  is  found  at  the  places  in- 
dicated above  according  to  the  stage  of  the  pregnancy.  The  greater 
part  of  the  uterus  is  lying  in  one  side,  usually  the  right,  the  fundus  is 
tipped  to  the  right,  the  left  edge  canted  forward,  which  is  felt  by 
means  of  the  round  ligaments,  the  left  being  nearer  the  median  line 
than  the  right,  which  latter  sometimes  is  not  accessible  to  the  touch. 

The  shape  of  the  uterus  differs  in  a  first  pregnancy  from  that  found 
in  the  following  ones,  being  ovoid  in  the  former  and  more  globular  in 
the  latter;  but  even  then  the  longitudinal  axis  is  longer  than  the 
transverse.     If,   on  the  contrary,  the  latter  exceeds  the  former,  we 


%\ 


r' 


V 


!'«! 


/    f  I  I 


PHYSICAL   EXAMINATION. 


109 


conclude  that  this  is  a  case  of  transverse  presentation.  We  notice  if 
in  a  first  pregnancy  the  head  remains  above  the  brim,  which  would 
mean  a  mechanical  disproportion  between  the  head  and  the  pelvis. 
In  pluriparae  we  see  if  the  fundus  hangs  forward  and  downward,  a 
condition  known  as  pendulous  abdomen. 

Fig.  144. 


Palpation  of  the  fundus  uteri  in  the  middle  of  the  seventh  month. 


After  having  finished  our  examination  of  the  uterus,  we  palpate 
the  foetus.  The  head  is  most  easily  recognized  as  a  large,  hard,  round 
body.  It  may  be  felt  between  the  two  hands  pressed  down  in  either 
iliac  fossa  (Fig.  146),  or  it  may  be  grasped  either  from  above  or  from 
below  with  one  hand  (Figs.  147,  148).  At  the  opposite  end  the 
breech  is  felt,  somewhat  similar,  but  smaller,  less  regular,  and  softer. 


110 


NORMAL   PREGNANCY. 


Between  the  two  we  feel  the  long  cylinclrical  back,  and  between  it  and 
the  head  the  neck  as  a  narrower  part  upon  which  the  fingers  can  be 
pressed  in.  Going  out  fi'om  the  breech  it  is  easy  to  map  out  the 
thighs.  What  is  left — namely,  legs  and  arms — is  called  the  small  parts, 
which  cannot  be  distinguished  from  one  another  by  themselves,  but 
sometimes  they  may  be  so  by  their  connection  with  the  larger  parts 
of  the  fetal  body.  If  the  head  is  neither  felt  at  the  symphysis  nor  at 
the  fundus,  we  feel  for  it  in  the  sides,  and  if  we  feel  it  there  we  know 
that  we  have  to  deal  with  a  cross  presentation. 

Fig.  145. 


'?.wia*Wii<^S?^^ 


■"^^ 


Palpation  of  the  'back  of  the  fcetu.s. 


If  the  back  is  not  felt  distinctly,  its  palpation  may  be  facilitated  by 
pressing  on  the  fundus,  which  bends  the  back  and  makes  it  more 
prominent. 

By  suddenly  pushing  the  hands  down  under  the  presenting  part, 
this  may  be  made  to  yield,  the  foetus  mounting  in  the  liquor  amnii  and 
sinking  back  again — ballottement.  If  the  head  is  engaged  in  the  true 
pelvis,  only  part  of  it  is  accessible  to  touch. 

It  is  not  only  the  presentation  that  can  be  made  out  through  the 
abdominal  wall,  but  to  some  extent  even  the  position.     The  fingers 


PHYSICAL   EXAMINATION.  IH 

:?an  be  introduced  deeper  on  the  side  where  the  more  pointed  occiput 
lies  than  on  that  occupied  by  the  broader  forehead  (Fig.  146).  If  we 
feel  the  small  parts  very  distinctly  and  over  a  large  area,  we  may 
conclude  that  they  lie  against  the  anterior  wall,  and  that  consequently 
the  occiput  is  turned  backward  (Fig.  149).  In  palpating  the  abdomen 
we  pay  attention  to  movements  of  the  foetus,  which  are  particularly 
well  marked  there  where  the  small  parts  are  situated. 

Fig.  146. 


\ 


\ 


'\ 


■^  ^sm 


Palpation  of  head  with  both  hands. 

Percussion  gives  a  flat  tone.  Auscultation  forms  an  important  part 
of  the  obstetric  examination.  Sometimes  we  hear  best  with  a  stetho- 
scope and  in  other  cases  with  the  ear  applied  to  a  thin  cloth  covering 
the  abdomen ;  but  the  latter  method  is  applicable  only  to  that  part  of 
the  abdomen  which  is  driven  well  forward  by  the  enlarged  uterus, 
since  the  hollow  formed  between  the  abdomen  and  the  thighs  pre- 
cludes a  proper  adaptation  of  the  ear.  A  binaural  stethoscope  is 
much  preferable  to  a  single.  It  presses  less  on  the  abdomen ;  the 
physician  can  reach  all  parts  of  the  abdomen  without  changing  his 


112 


NORMAL    PREGXAXCY 


position ;  and  the  stethoscope  conducts  a  larger  volume  of  sound, 
which,  when  the  sound  to  be  heard  is  weak,  is  an  advantage.  The 
sounds  become  much  more  distmct  if  we  extend  the  patient's  legs  or, 
still  better,  let  them  hang  down,  for  in  these  positions  the  legs  are  not 
in  our  way  and  the  uterus  is  brought  in  closer  contact  with  the  an- 
terior abdominal  wall.  We  listen  for  heart  sounds,  vmbiliccd-cord  sound, 
iderine  bruit,  and  fetal  movements.  The  left  occipito-anterior  position 
being  the  most  common,  the  heart  sound  is,  as  a  rule,  heard  most  dis- 

FiG.  147. 


Grasping  head  with  left  hand  from  above. 

tinctly  about  two  inches  below  and  to  the  left  of  the  umbilicus,  and, 
thereifore,  we  apply  the  stethoscope  first  to  this  place ;  but  whether 
we  hear  it  there  or  not,  we  extend  our  examination  in  all  directions, 
and  satisfy  ourselves  where  the  sound  is  most  distinct.  The  diagnostic 
value  of  the  different  places  in  Avhich  this  maximum  distinctness  is 
found,  the  character  of  the  sound,  and  its  frec]uency  have  been  dis- 
cussed above  in  describing  the  signs  of  pregnancy. 

The  urnhilical-cord  sound  is,  as  we  have  said,  rather  rare.     It  is 


PHYSICAL    EXAMINATION. 


113 


usually  single  and  synchronous  with  the  first  heart  sound,  but  it  may 
also  be  double.  It  is,  as  a  rule,  heard  at  some  distance  from  the 
place  of  maximum  intensity  of  the  heart  sound.  If  the  sound  is 
single,  it  is  sometimes  produced  by  compression  of  the  cord  between 
the  back  of  the  foetus  and  the  anterior  abdominal  wall,  of  which  we 
have  a  proof  in  the  fact  that  we  sometimes  can  produce  it  at  will  by 
pressure  with  the  stethoscope.     In  other  cases  it  seems  to  be  due  to 

Fig.  148. 


Grasping  head  with  right  hand  from  helow. 

the  increased  tension  of  the  cord  when  it  is  wound  around  the  neck 
or  an  extremity,  or  simply  has  an  unusually  large  number  of  turns. 
The  production  of  the  double  sound  has  been  attributed  to  an  unusual 
development  of  the  valves  found  both  m  the  umbilical  arteries  and 
veins.  These  different  sources  of  the  sound  would  also  explain  why 
in  some  cases  it  is  fugitive  and  in  others  permanent. 

The  uterine  souffle  or  bruit  has  been  described  above  as  among 
the  uncertain  signs  of  pregnancy,  and  the  fetal  inovement  as  one  of  the 

8 


114 


NORMAL   PEEGNANCY. 


certain  signs.  Besides  tlie  sounds  mentioned,  the  examiner  hears  the 
pulsation  in  the  mother's  aorta,  and  sometimes  wind  shifting  place  in 
the  intestine. 

For  the  vaginal  examination  the  feet  are  again  brought  up  to  their 
former  position.  During  the  greater  part  of  pregnancy  disinfection 
of  tlie  obstetrician's  hands,  unless  they  have  been  contaminated,  is 
not  called  for ;  and  often  we  do  not  know  that  we  have  to  deal  with 

Fig.  149. 


The  small  parts  of  the  fcetus  turned  against  the  anterior  abdominal  wall.    Left  oceipito-posterior 

position. 


a  case  of  pregnancy.  In  most  cases  the  woman  continues  her  marital 
relations,  and  the  parts  of  the  husband  that  come  in  contact  with  her 
are  certainly  not  disinfected.  Hence  common  cleanliness  as  for  any 
gynaecological  examination  suffices.  At  the  end  of  pregnancy  and 
during  labor,  on  the  other  hand,  there  would  be  danger  of  infection, 
and  therefore  the  most  scrupulous  disinfection  should  be  instituted, 


PHYSICAL   EXAMINATION.  115 

as  will  be  described  when  we  come  to  the  rules  for  the  conduct  of 
normal  labor. 

In  early  pregnancy,  while  the  uterus  is  still  totally  or  largely  in 
the  pelvis,  a  bimanual  examination  is  required.  The  obstetrician  stands 
now  at  the  end  of  the  table.  In  most  cases  it  suffices  to  introduce 
the  index-fmger  into  the  vagina.  It  should  be  made  slippery  by  being 
dipped  in  a  one  per  cent,  solution  of  lysol  or  in  sterilized  olive  oil  or 
glycerin.  The  three  other  fingers  are  bent  flat  against  the  hand,  so 
that  one  right  angle  is  formed  at  the  joints  between  the  metacarpus 
and  the  first  phalanges,  and  another  between  the  first  and  second 
row  of  phalanges.  The  index-finger,  again,  forms  a  right  angle  with 
the  first  phalanx  of  the  middle  finger,  and  the  thumb  is  extended  so 
as  to  form  a  right  angle  with  the  metacarpal  bone  of  the  index-finger 
(Fig.  150).  If  there  is  room  enough,  it  is  sometimes  well  to  introduce 
both  the  index  and  the  middle  finger  into  the  vagina,  which  allows  us 
to  penetrate  fully  an  inch  deeper.  In  entering  we  ascertain  by  palpa- 
tion or  eyesight  the  condition  of  the  perineum  and  the  hymen.  We 
notice  if  there  be  any  narrowness,  adhesions,  or  bands  in  the  vagina. 
Next  we  examine  the  place  and  condition  of  the  os,  especially  tears 
from  former  deliveries,  and  the  length  and  consistency  of  the  cervix. 
The  writer  takes  it  to  be  best,  as  a  rule,  not  to  enter  the  cervical  canal, 
as  by  so  doing  we  might  carry  microbes  into  it  from  the  vagina. 

While  examining  the  uterus  the  four  fingers  of  the  other  hand  are 
placed  on  the  fundus,  which  they  steady  and  press  down.  By  hold- 
ing the  uterus  between  the  fingers  of  both  hands  we  judge  of  its 
position,  shape,  and  size. 

If  the  vagina  is  spacious  enough,  we  carry  the  examining  fingers 
all  over  the  pelvic  walls  and  as  much  of  the  brim  as  we  can  reach, 
paying  full  attention  to  any  irregularity  or  abnormal  protuberances. 
We  also  test  the  mobility  of  the  os  coccygis.  We  notice  if  the  head 
is  engaged  in  the  pelvis  or  rests  above  the  brim.  We  can  also  get  a 
fairly  accurate  impression  of  its  size  by  placing  a  finger  on  it  in  the 
vagina  and  simultaneously  seizing  it  above  the  symphysis  between  the 
thumb  and  index  of  the  other  hand. 

Pelvimetry. — If  the  examination  arouses  some  suspicion  in  regard 
to  the  proportions  of  the  pelvis  and  the  head  of  the  child,  it  is  well 
at  this  stage  to  measure  the  pelvis.  Wliile  we  are  making  the  exam- 
ination of  the  pelvis,  we  apply  the  middle  finger  accompanied  by  the 
index-finger  to  the  middle  of  the  promontory,  press  the  radial  side 
of  the  metacarpal  bone  of  the  index-finger  tightly  against  the  lower 
end  of  the  symphysis  pubis,  and  mark  with  the  nail  of  the  other 
index-finger  how  far  the  fingers  enter  the  vagina  (Fig.  151).  Next 
the  fingers  are  withdrawn  from  the  vagina  and  the  distance  from 
the  mark  on  the  hand  to  the  tip  of  the  middle  finger  is  measured  with 


116 


NORMAL   PREGNANCY. 


Fig.  151. 


a  tape  measure.  If  the  promontory  is  readied  easily,  that  is  in  itself 
a  proof  that  the  distance  is  less  than  it  ouglit  to  be,— about  5  inches 
(thirteen  centimetres). 

To  complete  our  measurements  of  the  pelvis,  we  take  with  special 

calipers  (Fig.  152)  the  distance  be- 
tween the  two  anterior  superior 
spines — normally  about  10  inclies 
(twenty-six  centimetres),  and  that 
between  the  two  most  divergent 
points  of  the  crest  of  the  ihum — 
normally  about  11|  inches  (twenty- 
nine  centimetres).  In  taking  these 
measures  the  tops  of  the  calipers  are 
placed  just  outside  of  a  little  promi- 
nence which  is  felt  at  the  anterior 
superior  spine  and  against  the  outer- 
most point  of  the  crest. 

Finally,  the  woman  is  turned 
over  on  her  left  side  with  moder- 
ately bent  knees.  One  end  of  the 
calipers  is  placed  on  a  little  depres- 
sion found  just  under '  the  spinous 
process  of  the  fifth  lumbar  vertebra.  In  fat  women  this  point  may  not 
be  seen  or  easily  felt,  but  one  can  always  feel  tlie  posterior  superior 
spines  of  the  ilium.  If  we  unite  them  with  a  transverse  line,  the 
depression  between  the  last  lumbar  vertebra  and  the  sacrum  is  found 
about  a  quarter  of  an  inch  above  the  middle  of  the  line. 

Fig.  152. 


Internal  pelvimetry. 


Philander  A.  Harris's  pelvimeter. 


In  women  who  are  not  too  fat  a  rhomboid  figure  is  visible  at  the 
lower  end  of  the  spine, — rhomb  of  3Iichaelis  (Fig.  1 53).  Tlie  upper 
end  is  found  at  the  depression  between  the  fifth  lumbar  vertebra  and 


PHYSICAL    EXAMINATION. 


117 


Fig.  153. 


the  sacrum.     The  lower  end  is  situated  where  the  glutiEi  maxinii 

muscles  separate,  near  the  tip  of  the  coccyx,  and  the  outer  angles 

form  dimples  slightly  above  the  superior  posterior 

spines  of  the  ilium.     In  well-built   women  this 

figure  forms  a  regular  parallelogram,  but  in  those 

with  a  deformed  pelvis  it  becomes  irregular,  the 

upper  end  sinking  too  far  down. 

The  anterior  end  of  the  calipers  is  placed  at 
the  upper  end  of  the  symphysis  pubis,  taking 
good  care  not  to  press  it  in  above,  which  would 
give  too  short  a  distance,  nor  to  let  it  slide  down 
on  the  anterior  wall  of  the  symphysis,  which 
would  simulate  too  long  a  distance.  This  meas- 
urement is  called  the  diameter  of  Beaudelocque,  and 
measures  normally  8  inches  (twenty  centimetres). 

A  rectal  examination  is  rarely  needed  in  ob- 
stetrical cases.  If  it  is  wanted,  the  rectum  should 
be  emptied  by  the  administration  of  a  soap-suds 
enema.  The  patient  may  be  in  either  the  dorsal 
or  preferably  the  left  lateral  position.  The  exami- 
nation is  usually  made  with  the  index-fmger  alone, 
in  exceptional  cases  with  the  index  and  middle 
fmger  together,  but  then  the  patient  should  be 
anaesthetized.  The  space  under  the  finger-nail 
should  be  filled  with  soap,  in  order  that  it  may 
be  easily  cleaned  after  the  examination.  The  examining 
made  slippery  by  dipping  it  in  oil  or  smearing  it  with  vaseline  or  some 

It 


Tiie  rhomb  of  Michaelis. 


finger  is 


Fig..  154. 


other  greasy  substance. 


is  best  to  stand  behind  the 
patient  and  introduce  the 
right  index-finger,  which 
easily  reaches  the  superior 
sphincter. 

Rarely  an  inspection 
with  specidum  is  called  for. 
When  it  is  so,  we  may  in 
the  beginning  of  preg- 
nancy use  a  bivalve  spec- 
ulum, such  as  Brewer's 
(Fig.  154).  Later,  when 
the  vagina  is  much  soft- 
ened, there  are  such  large 

folds  that  they  obstruct  the  view.     Then  a  large  Sims  speculum  (Fig. 

155)  is  needed,  and  probably  a  depressor  to  hold  the  anterior  wall 


Brewer's  speculum. 


118 


NORMAL   PREGNANCY. 


out  of  the  way,  Sims's  speculum  is  used  with  the  patient  in  Sims's 
position  (Fig.  156).  The  patient  lies  on  her  left  side,  half  turned 
over  on  her  front.  The  left  side  of  the  face  rests  on  a  cushion,  the  left 
breast  touches  the  couch,  the  left  arm  is  placed  behind  the  body,  and 
if  the  table  is  narrow  both  arms  hang  down  at  the  sides  of  the  table, 

Fig.  155. 


Sims's  speculum. 

.but  if  it  is  too  broad  for  that  the  right  arm  may  be  placed  in  front  of 
the  face ;  the  nates  form  an  inclined  plane,  the  right  being  a  little 
nearer  the  head  and  in  front  of  the  left ;  the  right  leg  lies  on  the  left, 
but  is  drawn  a  little  higher  up  towards  the  pelvis.  In  order  to  intro- 
duce Sims's  speculum  the  shaft  is  held  with  the  left  hand,  and  the 


Fig.  156. 


Sims's  jxjsition. 


thumb  and  index-fmger  of  the  right  are  placed  along  the  blade  to  be 
introduced,  the  tip  of  the  index-fmger  overlapping  the  end  of  the 
speculum  and  opening  the  way  for  it  by  pushing  aside  the  labia 
majora  and  vaginal  folds  (Fig.  157). 

Hunter's  depressor  (Fig.  158)  is  a  double  spoon  made  of  flexible 


PHYSICAL    EXAMINATION. 


119 


silver-plated  copper.     It  is  held  witli  the  right  hand,  ^vhile  the  left 
holds  the  speculum. 

Garrigues's  depressor  (Fig.  159)  is  made  of  steel  and  is  held  with 
the  same  hand  as  the  one  holding  the  speculum.  Sims's  speculum 
being  in  place,  the  depressor  is  inserted  with  the  rigid  hand  and  its 


Fig.  157 


Introduction  of  Sims's  speculum. 

distal  loop  placed  in  front  of  the  cervix,  and  then  the  depressor  is 
seized  with  the  left  hand.  The  proximal  loop,  serving  as  handle,  is 
held  against  the  middle  portion  of  a  double  Sims  speculum  (Fig.  160). 
The  arch  in  the  middle  allows  fre.e  insight  into  the  vagina,  and  the 
obstetrician  retains  the  free  use  of  his  right  hand. 

In  inspecting  the  breasts  all  the  features  described  above  in  treat- 
ing of  the  changes  which  take  place  in  them  during  pregnancy — the 
development  of  Montgomery's  glands,  the  formation  of  the  secondary 
areola,  the  swelling  of  the  true  areola,  the  increase  in  size  of  the 
breasts,  the  enlarged  veins  running  over  them,  striae,  scales  on  the 
nipples,  the  presence  of  fluid  in  the  mammary  glands — should  be 

Fig.  158. 


Hunter's  depressor. 


cinhl 


he  exammer 


noticed ;  and  besides,  if  the  mother  is  to  nurse  the 
should  pay  attention  to  the  shape  of  the  nipple. 

In  cases  of  suspected  pregnancy  it  is  best  to  begin  the  whole 
examination  with  the  inspection  of  the  breast,  which  can  easily  be 
done  by  proposing  a  physical  examination  of  the  chest  with  the  steth- 


120 


NORMAL    PREGNANCY. 


oscope.  If  then  our  suspicion  is  corroborated  by  what  we  find  by 
the  mammary  examination,  it  is  much  easier  to  demand  permission 
to  institute  a  vaginal  examination  than  if  we  began  ^vith  a  rec]uest 

Fig.  159. 


Gairigues's  depressor. 

the  necessity  of  which  would  not  be  comprehensible  to  the  patient  or 
her  friends. 

If  the  abdominal  and  vaginal  examinations  are  made  in  the 
patient's  house  or  in  another  j)lace  where  there  is  no  examining- 
table,  it  is  best  to  let  the  patient  lie  in  bed  and  to  place  a  board — for 
instance,  one  of  those  lap-boards  so  commonly  found  in  private 
houses — under  her  buttocks,  in  order  to  prevent  her  from  sinking 
into    the    soft    bedding.      Under  these   circumstances    the   physician 


Fig.  160. 


How  to  hold  Gairigues's  depressor  with  speculum. 

takes  a  seat  at  the  side  of  the  bed  and  conducts  the  examination  as 
far  as  possible  under  cover  of  a  sheet,  while  blankets  and  quilts  are 

thrown  aside. 


DIAGNOSIS    BETWEEN    FIRST    AND   LATER    PREGNANCIES. 


121 


CHAPTER    XXVI. 
DIAGNOSIS   BETWEEN   THE    FIRST   AND    LATER    PREGNANCIES. 

Sometimes  the  obstetrician,  as  a  medical  expert,  is  asked  whether 
a  woman  is  in  her  first  pregnancy  or  has  borne  one  or  more  children. 
As  a  rule,  the  decision  is  easy,  but  in  rare  cases  even  experienced 
men  may  be  in  doubt. 

In  the  chapter  treating  of  copulation  we  have  seen  that,  as  a  rule, 
the  hymen  tears  in  one  or  more  places  by  the  penetration  of  the  male 
organ,  but  as  long  as  no  birth  or  miscarriage  has  taken  place  there  is 
no  loss  of  substance,  and  the  base  of  the  hymen  still  forms  an  un- 
broken ring  (Fig.  29,  p.  21).     The  passage  of  a  child,  on  the  other 

Fig.  161.   ' 


Hymen  of  woman  who  has  borne  one  child. 


hand,  causes  such  an  enormous  distention  and  bruising  that  large  por- 
tions of  the  thin  hymeneal  fold  are  destroyed.  The  remnants  shrink 
and  form  a  few  small  roundish  protuberances,  from  anticjuity  known 
as  caruncuioi  myrtiformes,  on  account  of  their  supposed  resemblance 
to  the  fruits  of  the  myrile-tree  (Fig.  161).  There  is  always  one  on 
either  side,  and  sometimes  one  or  two  more.  In  repeated  pregnancies 
they  sometimes  undergo  hypertrophy,  and  hang  coxcomb-like  out 
from  the  vaginal  entrance.  It  must,  however,  be  borne  in  mind  that 
parts  of  the  hymen  may  also  be  destroyed  by  gangrene  or  syphilitic 
ulceration. 


122 


NORMAL    PREGNANCY. 


The  vagina  of  a  primigravida  is  comparatively  narrow  and  has 
preserved  its  normal  columns  and  rugse.  In  the  plurigravida  the 
canal  is  wider,  smoother,  and  often  we  feel — in  consequence  of  a  tear 
of  the  levator  ani  muscle  and  its  two  accompanying  fasciae,  the  anal 
below  and  the  rectovesical  above,  at  a  preceding  birth — a  V-shaped 
gap  on  the  posterior  wall,  most  frequently  on  the  right  side. 

In  nulliparous  pregnant  women  the  cervical  portion  is  cone- 
shaped  and  longer ;  the  os  externum  is  small,  round,  and  closed,  ex- 
cept towards  the  end  of  pregnancy,  when  it  may  admit  the  fmger ; 
but  even  then  the  upper  part  of  the  canal  with  the  internal  os  remains 
closed.  In  women  who  have  given  birth  to  a  child,  the  cervical  por- 
tion is  cylindrical  and  shorter ;  the  os  externum  forms  a  transverse 

Fig.  162. 


Hypertrophy  of  vaginal  portion  in  a  virgin  simulating  a  laceration  of  the  cervix.    A,  side-view 
of  supposed  sagittal  section ;  B,  the  cervix  seen  from  below. 


slit  with  an  anterior  and  a  posterior  lip  ;  often  it  is  torn,  especially  in 
the  sides ;  the  os  is  open,  the  cervical  canal  is  funnel-shaped,  being 
widely  open  below  and  tapering  upward.  During  the  last  month  even 
the  internal  os  often  is  open  and  allows  one  to  place  the  finger  directly 
on  the  ovum  and  the  presenting  part.  Occasionally,  however,  two 
lips  may  form  in  a  nulliparous  woman.  The  writer  has  treated  an 
unmarried  lady  about  eighteen  years  of  age  for  anteversion  and  ante- 
flexion with  menorrhagia  and  profuse  leucorrhoea  in  whom  there  were 
two  thick  everted  lips,  the  anterior  measuring  one  inch  and  the  pos- 
terior three-fourths  of  an  inch  (Fig.  162).  The  cervical  canal  formed 
a  transverse  slit  one-fourth  of  an  inch  wide.  The  cavity  measured 
from  the  base  of  the  lips  to  the  fundus  two  and  three-fourths  inches. 


DIAGNOSIS    BETWEEN   FIRST   AND    LATER    PREGNANCIES.  123 

The  hymen  was  not  ruptured,  but  lax.  The  abdominal  wall  was  tense 
and  had  no  cicatrices.  She  had  probably  masturbated,  but  I  have 
every  reason  to  believe  that  she  had  never  had  connection.  On  a 
smaller  scale  the  writer  has  frequently  seen  a  cervix  with  two  lips  in 
virgins.  The  diagnosis  from  a  torn  cervix  is,  however,  easy  by  the 
softness  of  the  tissue  and  the  absence  of  any  cicatricial  plug  in  the 
angle  between  the  lips. 

Fig.  163. 


Diagram  of  a  sagittal  section  in  the  median  line  of  a  primigravida  in  the  last  month  of  {iregnancy. 

(Olshausen-Veit.) 

In  the  first  pregnancy  with  head  presentation,  the  head,  if  there 
is  no  disproportion  between  it  and  the  pelvis,  during  the  last  month, 
or  even  earlier,  sinks  down  into  the  pelvic  cavity  (Fig.  163),  or  is  at 
least  pressed  against  the  brim,  while  in  following  pregnancies  it  re- 
mains in  the  abdominal  cavity  till  the  end  of  pregnancy  (Fig.  164.) 

Towards  the  end  of  the  first  pregnancy  the  upper  part  of  the 
cervical  canal  is  taken  up  by  the  ovum,  and  consecjuently  the  re- 
mainder of  the  canal  is  shorter,  while  in  following  pregnancies  the 


124  NORMAL    PREGNANCY. 

head  does  not  descend  into  the  cervical  canal,  which  retains  its  whole 
length. 

The  fourchette  is  mostly  torn  during  childbirth,  and  then  we  will 
find  white,  hard,  cicatricial  lines  at  its  place.  In  this  connection  we 
should,  however,  remember  that  the  raphe  forms  a  somewhat  irreg- 
ular whitish  line  that  may  be  mistaken  for  a  cicatrix  after  a  healed 
perineal  tear. 

Fig.  164. 


Diagram  of  a  sagittal  section  in  the  median  line  of  a  plurigravida  in  the  last  month  of  pregnancy. 

(Olshausen-Veit. ) 

In  a  primigravida  the  abdominal  wall  is  tense,  the  fundus  uteri  is 
carried  more  backward,  and  there  are  only  purple — no  white — striae. 
In  a  plurigravida  the  abdominal  wall  is  flaccid,  easily  folded,  and 
marked  by  old  white  striae.  Sometimes  there  is  such  a  diastasis 
between  the  recti  and  the  pyramidales  muscles  that  the  uterus  feels  as 
if  it  were  lying  right  under  the  skin.  The  wall  may  even  become 
translucent,  so  that  small  myomas  on  the  surface  of  the  womb  or 
enlarged  vessels  may  be  seen. 


BACTERIOLOGY    OF   THE   VAGINA.  125 

During  the  first  pregnancy  the  breasts  preserve  much  of  their  elas- 
ticity and  stand  out  from  the  chest.  In  women  who  have  nursed  a 
child  they  are  pendulous.  Sometimes  there  are  cicatrices  from  a 
mammary  abscess.  The  nipple  is  in  the  first  pregnancy  broader  at 
its  base  than  at  the  apex,  while  after  lactation  it  becomes  globular 
and  pedunculated. 

There  is  hardly  any  absolutely  decisive  single  sign  by  Avhich 
the  question  Avhether  childbirth  has  gone  before  can  be  settled ;  but 
by  taking  all  the  signs  together  we  can  nearly  always  arrive  at  a 
positive  result.  It  is  much  more  difficult,  and  sometimes  impossible, 
to  tell  whether  or  not  a  woman  has  had  a  miscarriage.  A  small  foetus 
may  pass  the  genital  canal  without  causing  any  tears  leading  to  cica- 
trices. The  larger  the  foetus  is,  the  more  the  condition  will  approach 
that  described  above  for  cases  of  previous  childbirth. 


CHAPTER    XXVII. 

BACTERIOLOGY    OF   THE   VAGINA. 

Bacteriologists  differ  much  in  their  statements  about  the  bacte- 
ria found  in  the  vagina  of  pregnant  women,  a  subject  that  is  of  the 
greatest  importance  in  order  to  decide  whetlier  or  not  autoinfection  is 
possible,  and  whether  prophylactic  antiseptic  douches  should  be  given 
before  labor.  Based  on  the  examination  of  ninety-two  pregnant 
women,  Dr.  Witriclge  Wihiams,  professor  of  obstetrics  in  the  Johns 
Hopkins  University,  of  Baltimore,  corroborates  the  conclusion  arrived 
at  by  Kroenig  and  Menge,  that  no  pus-producing  bacteria — strepto- 
coccus pyogenes,  staphylococcus  aureus  or  albus — are  found  in  the 
vagina  of  pregnant  women.  Even  the  vaginal  secretion  of  unimpreg- 
nated  women  has  bactericidal  properties,  and  this  faculty  is  enhanced 
during  pregnancy.  According  to  these  authors,  the  positive  results  of 
their  opponents  are  due  to  the  faulty  way  in  which  they  obtained  the 
secretion,  leading  to  admixture  of  microbes  from  the  vulva  or  hymen. 
On  the  other  hand,  their  negative  results  are  attributed  by  their  ad- 
versaries to  the  use  of  unsuitable  substances  for  culture.  According 
to  them,  streptococci  are  found  in  the  vagina  of  twenty  per  cent,  of 
healthy  pregnant  women.  The  gonococcus  is  occasionally  found  in 
the  vaginal  secretion,  and  may  during  the  puerperium  extend  from 
the  cervix  into  the  uterus  and  tubes.  It  is  possible  that  the  vagina 
may  in  very  rare  instances  contain  bacteria  which  may  give  rise  to 
saprgemia  and  putrefactive  endometritis  by  autoinfection.  Some  of 
the  vaginal  bacilli  are  gas-producing.^ 

^  J.  Witriclge  Williams,  Trans.  Amer.  Gyn.  Soc,  1898,  vol.  xxiii.  pp.  141-183. 


126  NORMAL    PREGXAXCY. 

CHAPTER    XXVIII. 
DRESS    AXD    REGIMEX    DURIXG    PREGXAXCY. 

Although  a  pliysiological  condition,  pregnancy  is  so  often  accom- 
panied by  some  disturbance  of  the  woman's  health  tliat  slie  should 
take  particular  care  of  herself  during  that  period  and  prepare  herself 
for  the  ordeal  of  parturition  and  the  duties  that  ^vill  devolve  upon  her 
as  a  mother.  It  is  true  that  the  Indian  scjuaw  and  the  European 
field-worker  do  not  change  their  mode  of  living,  but  march  and  ride 
on  horseback  or  pick  up  stones  from  the  ground  till  labor  sets  in. 
But  what  suits  savages  and.  what  poor  people  are  obliged  to  do  for  a 
living  cannot  be  used  as  a  standard  for  the  civilized  woman  in  easy  cir- 
cumstances. There  is  no  doubt  that  by  hard  physical  exercise  many 
a  miscarriage  is  brought  on  that  might  have  been  avoided  under  more 
favorable  circumstances,  and  those  poor  women  lose  shape  and 
attractiveness  and  become  old  before  their  time.  Let,  therefore,  the 
man  who  can  afibrd  it  surround  his  pregnant  wife  with  all  the  care 
called  for  by  the  changes  going  on  in  her  body,  and  let  the  women 
themselves  forego  pleasures  that  are  injurious  and  at  the  same  time 
make  such  changes  in  their  habits  as  their  condition  rec|uires. 

In  general,  we  may  say  that  a  pregnant  woman  may  continue  to 
live  as  she  is  accustomed  to  do.  She  must  not  think  that  she  can- 
not work  and  walk  and  eat  and  drink  and  bathe  as  she  previously 
did,  provided  her  mode  of  livmg  was  a  natural  and  healthy  one.  If 
she  has  not  hygienic  halDits,  it  is  the  time  to  adopt  them  during  her 
pregnancy.  AVe  have  seen  above  that  during  pregnancy  the  blood 
becomes  thin,  as  the  pale  cheeks  and  lips  of  the  pregnant  woman 
tell  us,  without  counting  her  red  blood-coqjuscles.  The  act  of  giving 
birth  to  a  child  is  technically  called  labor.  For  most  women  it  is, 
indeed,  the  hardest  labor  they  are  called  upon  to  perform  in  the 
whole  course  of  their  lives.  When  their  hour  comes,  no  loving  hus- 
band nor  devoted  parent  can  take  the  burden  from  their  shoulders. 
Thus  two  indications  for  our  conduct  present  themselves.  The  preg- 
nant woman  should  have  substantial  food  and  fresh  air,  and  she 
should  use  her  muscles.  In  the  beginning,  when  she  suffers  much 
from  nausea  and  vomiting,  there  is  loss  of  appetite  with  danger  of 
inanition.  It  is,  therefore,  important  that  she  should  take  such  food 
as  she  can  retain  and  that  it  should  be  nutritious.  In  this  respect 
milk  is  the  best  of  all.  One  can  drink  when  it  is  impossible  to 
chew  solid  food.  Later,  as  a  rule,  she  has  a  voracious  appetite,  and 
must  then  be  cautioned  not  to  overload  her  stomach.  It  is  well 
to  take  two  or  three  small  meals  between  the  three  lai^e  ones.  She 
should  avoid  late  suppers  and  spiced  food.     Otherwise  she  may  eat 


DRESS    AND    REGIMEN    DURING    PREGNANCY.  127 

what  she  hkes,  and  if  she  is  accustomed  to  take  beer  or  light  wines 
with  her  meals,  there  is  no  reason  why  she  should  not  partake  of 
them  during  her  pregnancy.  Stronger  liquors  should  be  avoided,  as 
well  as  strong  tea  and  coffee.  She  should  have  plenty  of  sleep,  at 
least  eight  hours  out  of  the  twenty-four.  It  is  well  to  rest  an  hour 
in  the  middle  of  the  day,  whether  she  sleeps  or  not.  This  applies 
especially  to  the  last  three  months,  when  the  large  uterus  presses  on 
the  pelvic  organs  and  interferes  with  the  free  circulation  in  the  lower 
extremities.  The  longer  time  she  spends  in  the  open  air  the  better. 
It  is  also  advisable  to  leave  the  windows  of  her  bedroom  wide  open 
in  summer-time,  and  not  to  close  them  entirely  even  in  the  cold  sea- 
son. The  pregnant  woman  should  take  long  walks  every  day,  even 
in  bad  weather.  She  may  also  ride  in  street-cars  and  on  railroads, 
but  she  should  avoid  being  jolted  in  a  carriage  going  over  bad  roads. 
She  should  not  ride  on  horseback,  wheel,  dance,  jump  up  and  down 
stairs,  climb  mountains,  play  tennis,  skate,  or  swim.  Light  gymnastic 
movements,  giving  the  arms  a  similar  chance  to  be  used  to  that  which 
the  legs  have  in  walking,  are  to  be  encouraged.  There  is  no  reason 
why  she  should  not  make  a  bed  or  prepare  a  meal  if  she  is  wont  to 
do  so. 

She  should  have  a  movement  of  the  bowels  at  least  once  a  day. 
As  there  is  a  tendency  to  constipation,  often  special  measures  have 
to  be  taken  to  obtain  this.  Nearly  all  fruits  and  vegetables  have  an 
aperient  effect  and  should,  therefore,  form  part  of  the  diet.  Espe- 
cially grapes  and  oranges  taken  before  breakfast  are  useful.  If  any 
medicines  are  prescribed,  they  should  be  of  the  mildest,  such  as  mag- 
nesia, rhubarb,  cascara,  or  senna.  But  the  writer  has  found  that 
some  of  the  worst  cases  of  constipation  yield  to  the  regular  use  of 
distilled  water,  of  which  a  cjuart  is  drunk  on  an  empty  stomach 
every  morning,  a  tumblerful  every  quarter  of  an  hour.  Salines  are 
said  to  have  an  injurious  influence  on  the  development  of  the  child, 
especially  on  that  of  the  bones.  If  the  woman  has  not  had  a  move- 
ment in  the  course  of  the  day,  she  should  take  an  enema  of  a  quart 
of  soapsuds  before  retiring. 

In  the  choice  of  clothing,  the  leading  ideas  should  be  to  secure 
sufficiently  warm  wearing  apparel,  avoiding  pressure  and  heavy  weight 
on  the  abdomen.  The  decollete  dress  of  society  leaving  half  the  chest 
unprotected  is  out  of  the  question.  The  pregnant  woman  should  be 
covered  with  woollen  underwear  all  over  her  body  up  to  the  neck. 
Then  she  will  not  need  many  articles  of  dress.  Her  petticoats  are 
loosely  buttoned  or  bound  around  the  waist.  The  common  corset, 
exercising  great  pressure  in  the  direction  of  the  pelvis,  should  be  pro- 
scribed. The  woman  should  either  go  without  any  or  have  one  of 
those  especially  made  for  the  purpose  without  steels  or  whalebones. 


128  NORMAL   PREGNANCY. 

On  the  other  hand,  an  abdominal  supporter,  preferably  made  of  flan- 
nel, is  recommendable,  especially  in  repeated  pregnancies.  It  pre- 
vents too  great  a  distention  of  the  abdominal  wall  and  is  thus  service- 
able in  helping  the  woman  to  regain  her  shape  after  delivery,  and  not 
look  as  if  she  were  always  pregnant  or  suff'ering  from  an  abdomi- 
nal tumor.     Round  garters  should  be  replaced  by  side  garters. 

The  woman  should  take  a  lukewarm  bath,  about  95°  F.,  once  a 
week,  and,  as  there  usually  is  some  increase  of  vaginal  secretion,  she 
should  wash  the  perineum  daily  with  lukewarm  water.  If  the  secre- 
tion constitutes  a  discharge  that  irritates  the  skin,  there  is  no  objection 
to  vaginal  injections  medicated  with  mild  astringents,  such  as  borax 
or  alum,  of  lukewarm  temperature,  and  in  small  quantities  (3!  to 
Oi),  once  or  twice  a  day.  Surf  bathing  should  be  forbidden,  but 
there  is  no  objection  to  still  water  baths  of  short  duration, — maxi- 
mum, a  quarter  of  an  hour. 

The  nipples  should  be  washed  and  kept  free  from  crusts.  If  they 
are  short,  they  may  be  pulled  upon  several  times  daily  in  order  to 
elongate  them  and  render  them  more  fit  for  lactation.  If  there  are 
none,  they  cannot  be  formed,  and  the  woman  cannot  nurse  her  child. 
Their  skin  may  be  mollified  by  daily  inunction  with  albolene,  lanolin, 
cold-cream,  or  other  greasy  substances,  and  it  may  be  hardened  by 
washing  it  with  brandy  or  cologne  or  painting  it  with  a  solution  of 
tannic  acid, — e.g.^  glycerite  of  tannin  (si  to  si).  It  is  doubtful  if  these 
measures  prevent  sore  nipples  during  lactation,  which  seem  to  be  an 
unavoidable  accompaniment  of  its  earlier  stage  ;  but  the  patient  likes 
to  do  something  to  prepare  herself,  and  might  take  her  physician  to 
task  if  he  had  not  advised  any  preventive.  The  nipples  should  be 
protected  against  pressure  from  the  clothing. 

The  mental  condition  should  not  be  neglected.  It  is  much  better 
for  the  pregnant  woman  to  have  pleasant  company  than  to  brood  in 
idle  solitude  over  her  coming  confinement.  Friends  should  carefully 
abstain  from  all  grewsome  stories  and  preserve  her  from  anxiety  and 
worry.  Perusal  of  light  literature,  interest  in  what  is  going  on  in  the 
world,  and  attention  to  daily  duties  are  all  valuable  elements  of  a 
healthy  mental  atmosphere. 

Under  ordinary  circumstances  connection  can  hardly  be  totally 
avoided,  but  any  excess  in  this  direction  should  be  deprecated.  In 
women  who,  on  account  of  anteflexion  of  the  uterus,  conceive  with 
difficulty  and  easily  lose  the  foetus,  the  writer  forbids  intercourse  in 
the  third  and  the  sixth  months,  periods  at  which  abortion  is  particu- 
larly liable  to  occur. 

The  physician  should  examine  the  urine  for  albumin,  even  in 
apparently  healthy  women,  at  least  once  a  month. 


PART    III.— NORMAL    LABOR. 


CHAPTER    I. 
CAUSES   OF   LABOR. 

In  a  general  way  one  may  say  that  labor  begins  when  the  time 
has  come.  Why  this  period  in  woman  and  the  cow  should  be  about 
nine  months,  in  the  elephant  about  twenty  months,  and  in  dogs  about 
two  months  cannot  be  told  any  more  than  why  morphine  makes  one 
sleep  and  coffee  keeps  one  awake.  As  the  great  German  poet-philos- 
opher Goethe  says,  "Care  has  been  taken  that  trees  do  not  grow  into 
heaven"  ("Es  ist  dafiir  gesorgt  class  die  Biiume  nicht  in  den  Himmel 
wachsen'').  There  is  a  regulating  power  that  has  bound  natural 
processes  within  certain  limits  of  time  and  space.  But  we  may  per- 
haps find  what  means  are  employed  to  determine  the  transition  from 
pregnancy  to  labor.  In  all  probability  there  are  several  causes  oper- 
ating in  combination  with  one  another.  Fatty  degeneration  of  the 
decidua  makes  a  foreign  body  of  the  ovum,  which  irritates  the  nerves 
of  the  uterus  and  produces  muscular  contraction,  in  a  way  similar  to 
that  in  which  a  bougie  works  which  we  introduce  into  the  cavity  of 
the  uterus  when  we  want  to  induce  premature  labor  or  strengthen 
ineffective  labor  pains.  When  this  theory  is  impugned  on  the 
ground  that  uterine  contraction  sets  in  even  in  cases  of  extra-uterine 
pregnancy,  it  must  be  remembered  that  even  in  ectopic  gestation  a 
decidua  is  formed  and  has  to  be  expelled. 

In  the  placenta  a  change  gradually  takes  place,  the  intervillous 
spaces  becoming  reduced  in  size  by  an  invasion  of  giant  cells, 
which  begin  to  appear  among  the  decidual  cells  as  early  as  the  third 
month,  and  gradually  cause  a  thrombosis  of  the  sinuses.  The  effect 
of  this  process  is  to  render  the  blood — both  that  of  the  mother  and 
that  of  the  foetus — more  venous  in  character,  and  a  surplus  of 
carbonic  acid  in  the  blood  makes  the  uterus  contract.  When  under 
Louis  Philippe  the  French  army  was  warring  in  Algeria,  a  tribe  of 
Kabyles  sought  refuge  in  a  large  cave.  The  French  general  built  a 
fire  at  the  entrance.  Those  in  the  cave  were  suffocated,  and  it  was 
found  that  all  pregnant  women  in  the  trilDe  had  aborted. 

In  consequence  of  the  growth  of  the  child  the  trnsion  in  the 
wall  of  the  uterus  becomes  greater  and  greater,  and  there  must  come 
a  moment  when  the  expansion  can  go  no  further.  This  tension, 
combined  with  the  weight  of  the  foetus,  presses  the  latter  against  the 

9  129 


130  NORMAL    LABOR. 

internal  os,  and,  on  the  other  hand,  the  cervix,  gradually  opening 
both  from  below  and  above,  offers  less  resistance  to  the  pressure  from 
above. 

Perhaps  the  congestion  to  the  uterus  that  out  of  pregnancy  takes 
place  every  four  weeks,  and  induces  the  menstrual  flow,  continues  in 
the  pregnant  woman,  and  at  the  end  of  the  tenth  lunar  month  results 
in  labor. 

The  exciting  cause  that,  finally,  makes  the  uterus  contract  suf- 
ficiently to  dilate  the  cervix  and  expel  the  foetus  is  doubtless  irritation 
of  the  large  cervical  ganglion,  which  in  the  pregnant  condition  attains 
such  enormous  dimensions,  be  the  stimulus  mere  mechanical  pressure 
or  be  it  of  a  chemical  nature.  So  much  is  sure,  that  the  beginning 
of  labor  may  be  hastened  by  physical  exertion  and  retarded  by  rest. 
Often  it  is  brought  about  by  strong  mental  emotions, — fright  or  joy. 
Opium  retards  it  and  aperient  medicines  further  it.  A  busy  down- 
town practitioner  of  the  writer's  acquaintance  manages  sometimes 
to  attend  personally  to  five  confinements  in  one  day  by  a  judicious 
use  of  hypodermic  injections  of  morphine  in  some  cases  and  the 
admmistration  of  a  dose  of  castor  oil  in  others.  Ambitious  house- 
surgeons  in  Maternity  Hospital,  wanting  to  have  as  many  cases  as 
possible  when  their  term  of  service  was  drawing  to  an  end,  used  to 
give  castor  oil  to  all  the  women  in  the  waiting  ward  who  were  at  the 
end  of  pregnancy. 


CHAPTER    II. 

THE  AXATOMY  OF  THE  PARTURIENT  CAXAL. 

The  parturient  canal — that  is,  the  parts  through  which  the  foetus 
passes  in  a  normal  birth — is  composed  of  hard  and  soft  parts.  The 
hard  part  is  formed  by  the  bony  pelvis  ;  the  soft  by  the  muscles  that 
line  it,  the  uterus,  the  vag'ina,  and  the  vulva. 

A.    The  Pelvis. 

§  1.  Bones  of  the  Pelvis. — The  reader  is,  of  course,  supposed  to 
have  studied  anatomy,  so  that  it  will  be  necessary  only  briefly  to  refresh 
his  memory  and  then  to  examine  the  pelvis  from  the  obstetrician's 
stand-pomt. 

The  pelvis  is  the  large  bony  structure  intervening  between  the 
vertebral  column  and  the  lower  extremities.  IL  is  composed  of  four 
bones,  two — the  sacrum  and  the  coccyx — situated  in  the  median  line 
and  behind,  and  two — the  hip-bones — placed  laterally,  on  either  side 
and  in  front. 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


131 


The  SACRUM  of  the  adult  woman  is  a  strong,  somewhat  pyramidal 
?jone,  on  which  we  distinguish  a  base,  an  apex,  an  anterior  and  a 
posterior  surface,  and  two  lateral  edges.  The  central  part  of  the  base 
is,  by  means  of  a  fibrocartilaginous  disk,  like  that  connecting  the 
vertebree,  joined  to  the  fifth  lumbar  vertebra.  Laterally  it  is  expanded 
into  the  so-called  afe,  or  wings.  Behind  the  central  fibrocartilage  is 
a  triangular  opening  leading  into  the  sacral  canal,  on  either  side  of 
which  is  an  articular  process  articulating  with  the  corresponding  pro- 
cess of  the  fifth  lumbar  vertebra.  The  apex  is  very  much  smaller 
than  the  base,  and  has  the  shape  of  a  transverse  narrow  oval  articu- 
lating with  the  coccyx. 


Fig.  165. 


Fig.  166. 


The  anterior  surfaces  of  the  sacrum  and  coc- 
cyx. A,  ala,  or  wing ;  B,  articular  process  ;  C, 
first  anterior  sacral  foramen  ;  D,  articular  sur- 
face connected  with  the  body  of  the  fifth  lum- 
bar vertebra  ;  E,  line  of  coalition  between  first 
and  second  sacral  vertebra ;  F,  promontory  ;  O, 
articular  surface  connected  with  the  coccyx. 


The  posterior  surfaces  of  the  sacrum  and 
coccyx.  /,  sacrum  :  A,  sacral  crest ;  B,  first  pos- 
terior sacral  foramen  ;  C,  articular  surface  con- 
nected with  the  body  of  the  fifth  lumbar  verte- 
bra ;  D,  articular  process  in  contact  with  the 
corresponding  process  of  the  fifth  lumbar  ver- 
tebra ;  E,  eminences  representing  the  articular 
processes  of  the  sacral  vertebra3 ;  F,  eminences 
representing  the  transverse  processes ;  <?,  apex ; 
H,  cornua ;  /,  auricular  surface.  II,  coccyx : 
A,  cornua  ;  B,  apex  ;  C,  transverse  process. 


The  anterior  surface  (Fig.  165)  is  strongly  concave  from  above 
downward  and  slightly  so  from  side  to  side.  On  either  side  are  four 
openings,  anterior  sacral  foramina^  leading  into  the  sacral  canal.  Out- 
ward these  holes  are  continued  as  furrows  for  the  sacral  nerves. 
Transverse  bony  ridges  extend  between  each  two  holes  across  the 
median  line,  marking  the  places  where  the  bodies  of  the  five  vertebrEe 
of  which  the  sacrum  is  originally  composed  have  grown  together. 
Where  the  anterior  surface  joins  the  central  articular  surface  of  the 
base  is  a  projecting,  strongly  convex  line,  called  i\\Qp7'omontory^  which 


132 


^'ORMAL    LABOR. 


behind  merges  in  the  ala.     Outside  of  the  promontory  is  a  smooth, 
thick,  rounded-oif  edge,  separatmg  the  anterior  surface  from  the  ala. 

The  posterior  surface  (Fig.  166)  is  strongly  convex  from  above 
downward  and  somewhat  so  from  side  to  side.  It  is  narrower  than 
the  anterior  surface,  and  very  rough,  serving  for  the  attachment  of 
the  powerful  erector  spinse  muscle.  In  the  median  line  are  three  or 
four  small  eminences,  the  sjjinoKs  processes,  usually  more  or  less  con- 
nected with  one  another,  so  as  to  form  a  ridge,  the  sacral  crest.  Be- 
low this  ridge  is  a  triangular  openmg,  the  lower  end  of  the  sacral 
canal,  the  sides  of  which  end  in  small  processes,  the  sacral  cornua, 
which  articulate   with   the   cornua  of   the  coccyx.     Outside   of   the 


Fig.  167. 


Fig.  168. 


Emr^^ 


Lateral  edge  of  the  sacrum.  A.  surface  ar- 
ticulating with  the  body  of  the  fifth  lumbar 
vertebra ;  B,  superficies  auricularls  ;  C,  articu- 
lar process ;  D,  tubercles  and  hollows  for  the 
attachment  of  the  sacro-iliac  ligaments;  E, 
sacral  crest ;  F,  coccyx. 


The  sacral  canal.  A,  promontory ;  B,  apex 
of  sacrum  ;  C,  apex  of  coccyx.  27  indicates  the 
depth  of  the  sacral  hollow, — 27  millimetres,  or 
a  little  over  an  inch. 


central  ridge  is  a  shallow  groove  formed  by  the  united  laininpe  of  the 
original  sacral  vertebrae.  Outside  of  this,  agam,  are  found  four  jjos- 
terior  sacral  foramina,  correspondmg  to,  but  smaller  than,  the  anterior, 
and  leading  into  the  sacral  canal.  Inside  of  each  hole  is  a  small 
eminence  representing  the  articular  process,  and  outside  a  larger  one, 
corresponding  to  a  transverse  process. 

The  side  edges  (Fig.  167)  have  above  a  large  S-shaped  surface, 
superficies  auricularis,  wliich  articulates  with  the  hip-bone.  Behind 
this  are  deep  depressions  for  the  attachment  of  ligaments.  Tlie 
middle  part  of  the  side  edge  is  concave  and  rough  and  serves  for  the 
attachment  of  the  sacrosciatic  ligaments.  The  lowest  part  forms 
together  with  the  coccyx  a  notch  for  the  fifth  sacral  nerve. 


THE    ANATOMY    OF    THE    PARTURIENT   CANAL. 


The  sacral  canal  (Fig.  168)  is  carved  like  the  bone,  and  contains 
the  Cauda  equina. 

The  COCCYX  (Fig-s.  1G5,  166)  is  a  small  triangular  bony  mass,  com- 
posed of  four  rudimentary  vertebra?,  wliich  in  middle  life  usually 
grow  together  ^\'ith  one  another,  and  in  advanced  age  also  with  tlie 
sacrum.  In  tlie  middle  of  the  base  is  an  oval  surface  articulating  with 
the  apex  of  the  sacrum.  Laterally  and  behind  are  two  small  articular 
processes,  called  cornua,  which  articulate  with  the  cornua  of  the 
sacrum.  On  the  lateral  edge  of  the  first  coccygeal  vertebra  is  a  trans- 
verse process,  forming  together  with  the  lower  part  of  the  side  edge  of 
the  sacrum  a  notch  for  the  fifth  sacral  nerve.  The  three  other 
vertebrae  are  smaller  than  the  first  and  are  only  rudimentary  bodies. 

The  HIP-BONE,  OS  cox^,  or  os  innominatum,  an  irregular,  large,  and 
strong  bone,  has  a  shape  that  somewhat  suggests  a  figure  8.  It  is 
originally  composed  of  three  bones,  the  ilium  above,  the  ischium  below, 
and  ihe  piibes,  or  os  pubis,  in  front,  meeting  in  the  acetabulum,  or  coty- 
loid cavity,  a  deep  hollow,  forming  the  articulation  with  the  thigh-bone. 

Fig.  169. 


The  hip-bone,  outer  surface.  A,  acetabulum  ;  B,  ilium ;  C,  ischium  ;  1>,  pubes ;  E,  crest  of  ilium ; 
F,  anterior  superior  spine  of  ilium  ;  G,  posterior  superior  spine  of  ilium  ;  //,  anterior  inferior  spine 
of  ilium  ;  /,  posterior  inferior  spine  of  ilium  ;  ./,  great  sciatic  notch  ;  K.  spine  of  the  ischium ;  7., 
tuberosity  of  the  ischium  ;  M,  obturator  foramen  ;  X,  spine  of  the  pubcs  ;  O,  iliopectineal  eminence. 

The  ilium  (Fig.  169)  has  a  shovel-like  shape  and  extends  upward 
and  to  the  side.  Its  upper  border  is  thick  and  somewhat  S-shaped 
and  is  called  the  cre-sf.     At  its  ends  it  runs  out  into  small  pointed 


134 


NORMAL    LABOR. 


processes,  the  anterior  superior  and  the  posterior  superior  spine.  Under 
each  of  them  is  found  another  process,  the  anterior  inferior  and  tlie 
p)osterior  inferior  spAne.  The  outer  surface  serves  for  the  attachment 
of  tlie  massy  gluteal  muscles  (Fig.  170).  The  inner  forms  a  large  flat 
hollow,  cahed  the  iliac  fossa,  where  often  the  head  of  the  foetus  finds 
a  resting-place.  Behind  the  iliac  fossa  is  the  large  auricular  surface, 
articulating  with  the  corresponding  surface  of  the  sacrum.  Inside  from 
the  iliac  fossa  is  a  smooth  thick  line,  the  iliac pjortion  of  theiliopjectineal 
line.  Behind  the  articular  surface  are  rough  surfaces  for  the  attach- 
ment of  the  iliosacral  ligaments  and  the  erector  spinas  muscle. 

Fig.  170. 


The  hip-bone,  inner  surface.  A,  iliac  fossa  ;  B,  auricular  surface  ;  C,  iliac  portion  of  iliopecti- 
neal  line  ;  i>,  tuberositj-  of  the  ischium  ;  E,  spine  of  the  ischium  ;  F,  ascending  branch  of  ischium  ; 
(?,  body  of  pubes  ;  H,  symphj-sis  pubis  ;  I,  descending  ramus  of  pubes  ;  J,  ascending  ramus  of  pubes  ; 
K,  iliopectineal  eminence  ;  L,  obturator  foramen  ;  .V,  anterior  superior  spine  of  ilium  ;  ^V,  anterior 
inferior  spine  of  ilium  ;  0,  posterior  superior  spine  of  ilium  ;  P,  posterior  inferior  spine  of  ilium. 

On  the  ischium  we  remark  the  large  tuberosity  that  serves  as  support 
for  the  body  in  the  sitting  posture,  and  behind  that  a  small,  flat,  tri- 
angular projection,  the  spine  of  the  ischium,  which  is  of  great  obstetric 
importance,  both  as  a  landmark  and  as  a  point  that  influences  the 
movement  of  the  head  of  the  foetus  during  labor.  The  ischium  has  a 
smooth  concave  inner  surface,  a  continuation  of  that  of  the  ilium,  and 
joins  the  os  pubis  by  means  of  its  ascending  branch. 

The  p)ubic  bone,  or  os  pubis,  has  inward  a  quadrangular  body,  the 
posterior  surface  of  which  is  smooth,  slightly  concave  from  side  to 
side,  and  slightly  convex  from  above  downward.  The  anterior  sur- 
face is  roudi  and  serves  for  the  attachment  of  muscles  going  down  to 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


135 


the  thigh.  On  its  inner  border  it  articulates  with  the  corresponding 
surface  of  the  other  pubic  bone,  forming  the  symjjhysis  pubis.  Below 
the  body  the  descending  ramus  merges  in  the  ascending  ramus  of  the 
ischium.  Above  the  body  extends  the  ascending  ramus.,  near  the 
outer  end  of  which  is  situated  the  low  iliopedineal  eminence.  Outside 
of  the  upper  end  of  tlie  sympliysis  is  a  rough  surface,  called  the  crest., 
and  terminating  outward  in  the  pointed  spine^  from  which  a  sharp 
edge,  the  pubic  portion  of  the  iliopectineal  line,  extends  to  the  iliopec- 
tineal  eminence.  Between  the  ischium  and  the  pubis  is  a  large  oval 
opening,  called  the  obturator  foramen. 

§  2.  The  Lig-aments  of  the  Pelvis. — The  pelvic  bones  are  bound 
together  by  strong  ligaments.  Between  the  sacrum  and  the  ilium  there 
is  the  so-called  synchondrosis,  which  in  reality  is  a  joint  with  a  synovial 
membrane  (Fig.  171).     On  the  iliac  side  is  a  central  prominence  be- 

FiG.  171. 


Horizontal  section  througla  the  left  sacro-iliac  articulation.    Actual  size.    (Luschka.) 

tween  two  hollows,  and  on  the  sacral  side  a  corresponding  central 
concavity  between  two  convexities.  By  this  arrangement  a  kind  of 
screw  is  formed,  which  permits  a  limited  movement.  Independently 
of  pregnancy  and  in  both  sexes  the  sacrum  is  slightly  movable,  the 
promontory  tipping  forward  and  the  apex  backward  during  defecation. 
During  pregnancy,  when  the  parts  composing  the  joint  are  softened, 
this  motility  is  much  increased,  which  allows  the  promontory  to  recede 
during  the  beginning  of  labor,  and  the  apex  to  be  pushed  back  when 


136 


NORMAL    LABOR. 


Fig.  1^ 


the  head  is  passing  through  the  lower  part  of  the  pelvis  (Fig.  172).    The 
sacro-iliac  articulation  is  strengthened  by  the  anterior  sac ro-iUae  ligament 

in  front,  and  the  particularly  strong 
posterior  sacro-iliac  ligament  behind, 
which  prevents  the  sacrum  from 
falling  into  the  pelvic  cavity. 

Between   the    sacrum    and  the 
ischium  we  have  the  great   sacra- 
sciatic  ligament,   or  the    ligamentum 
tuber oso-sacrale,    and    in    front    of 
that  the  lesser  sacrosciatic  ligament, 
or   ligamenfirn  spinoso-sacrale.     By 
these  two  ligaments  the  sacrosciatic 
notches  are  converted  into  two  fo- 
ramina, the  superior  or  great  sacro- 
sciatic foramen  and  the  inferior  or 
lesser  sacrosciatic  foramen  (Fig.  17-3). 
Between   the  sacrum   and   the 
coccyx  is  found  a  fibrous  disk,  and  in  it  sometimes  a  sjmo^ial  mem- 
brane.    Between  the  cornua  are  interarticular  ligaments.     The  union 

Fig.  173. 


Diagram  .showing  the  oscillatory  move- 
ments of  the  sacrum.  (Duncan.)  ab,  sym- 
physis  pubis  ;  c,  c,  promontory  ;  d,  d,  apex  of 
coccyx. 


The  ligaments  of  the  pelvis.  A.  iliolumbar  ligament ;  B,  anterior  .sacro-iliac  ligament ;  C,  sacro- 
iliac articulation ;  D,  great  sacrosciatic  ligament ;  E,  lesser  sacrosciatic  ligament ;  F.  great  sacro- 
sciatic foramen  ;  G,  lesser  sacrosciatic  foramen ;  H,  sacrococcygeal  articulation ;  /,  symphysis 
pubis;  J,  obturator  membrane;  K.  Poupart's  ligament;  L,  Gimbernat's  ligament. 

between  the  two  bones  is  strengthened  by  the  anterior,  the  posterior., 
and  the  lateral  sacrococcygeal  ligaments. 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


137 


The  two  pubic  bones  are  bound  together  by  a  disk  of  cartilage  and 
fibrocartilage,  the  symphysis  pubis  (Fig.  174),  which  is  much  thicker 
in  front  than  behind  and  contains  a  small  cavity  with  an  imperfect 
synovial  membrane.  The  synchondrosis  is  strengthened  by  the  an- 
terior, the  posterior,  and  the  superior  pubic  ligament  and  the  subpubic 
ligament.  The  last  is  a  thick  triangular  arch  of  sinewy,  arched  fibres, 
forming  the  upper  limit  of  the  pubic  arch.  During  pregnancy  the  joint 
of  the  symphysis  becomes  softened  and  admits  some  degree  of  sliding. 

The  obturator  foramen  is  closed  by  a  thin  fibrous  membrane,  the 
obturator  membrane,  from  which  spring  the  obturator  internus  and  06- 
turator  externus  muscles. 

In  the  perineum  we  have  two  strong  ligaments,  the  transverse  liga- 
ment of  the  pelvis  and  the  ischioperineal  ligament.  The  transverse  liga- 
ment of  the  perineum  is  a  strong  ligament  lying  immediately  behind  and 
below  the  subpubic  ligament,  together  with  which  it  strengthens  the 

Fig.  174. 


Horizontal  section  of  symphysis  pubis.     (Luschka.) 


symphysis  pubis.  The  ischioperineal  ligament  is  a  strong  fibrous  band 
inserted  on  the  ischium  just  in  front  of  the  tuberosity.  It  goes  trans- 
versely through  the  pelvic  outlet,  at  the  posterior  margin  of  the  trans- 
versus  periuEei  muscle,  and,  being  connected  with  the  fasciae  of  the 
perineum,  it  constitutes  the  chief  support  of  the  pelvic  floor. 

§  3.  The  Pelvis  as  a  "Whole. — The  pelvis  (Fig.  175)  has  its  name 
from  its  supposed  likeness  to  a  barber's  basin, — in  Latin  called  pelvis. 
By  the  iliopectineal  line,  its  continuation  on  the  ala  of  the  sacrum, 
and  the  promontory — a  line  which  as  a  whole  is  sometimes  designated 
liaea  terminalis — it  is  divided  into  a  larger  upper  and  a  smaller  lower 
part,  respectively  called  the  large  or  false  pelvis  and  the  small  or  true 
pelvis.  The  cavity  of  the  false  pelvis  forms  part  of  the  abdominal 
cavity,  while  that  of  the  true  pelvis  is  specifically  called  the  pelvic 
cavity.  The  cavity  of  the  false  pelvis  is  closed  in  front  by  the  ab- 
dominal wall.  It  is  of  obstetrical  interest  only  in  so  far  as  in  pluri- 
parse  the  head   during  gestation  often  is  found  in  one  of  the  iliac 


138 


iVORMAL  LABOR. 


fossae,  and  because  by  measuring  the  false  pelvis,  Avhich  is  much  more 
accessible,  we  are  enabled  to  form  an  idea  of  the  dimensions  of  the 
true. 

Measurements  of  the  dry  bony  pelvis  are  needed  in  describing  and 
comparing  it  with  others.  They  are,  of  course,  smaller  than  the  cor- 
responding measurements  taken  during  life,  all  the  soft  parts  having 
been  removed.  The  ciistances  measured  on  the  false  pelvis  are  that 
between  the  anterior  superior  spines  of  the  ilium  (Sp.  II.),  which  is 
9  inches  (twenty-three  centimetres),  and  that  between  the  most  di- 
vergent points  of  the  crests  (Cr.  II.),  which  is  10  inches  (twenty-five 
centimetres).     Pelves  differ  in  size  in  different  individuals,  and  these 

Fig.  175. 


The  normal  female  pelvis.  A,  sacrum ;  B,  coccyx ;  C,  crest  of  the  ilium ;  D,  acetabulum ;  E, 
spine  of  the  ischium  ;  F,  symphysis  pubis ;  G,  spine  of  the  pubes ;  H,  obturator  foramen  ;  I,  tuber- 
osity of  the  ischium  ;  J  J  J,  linea  terminalis. 


figures,  as  well  as  the  others  that  follow,  represent  only  the  average 
found  by  measuring  a  large  number  of  pelves,  and  they  give  the  aver- 
age only  approximately,  leaving  out  of  consideration  small  fractions, 
that  would  embarrass  the  memory  without  being  of  practical  value. 

The  true  pelvis  is  of  much  greater  importance,  and  an  accurate 
knowledge  of  it  is  an  absolute  requisite  for  good  obstetric  work.  It 
forms  a  somewhat  cylindrical  curved  canal,  the  upper  opening  of  which 
is  called  the  inlet,  the  superior  strait,  or  the  brim  of  the  pelvis.  The 
lower  opening  is  called  the  outlet,  or  the  inferior  strait,  and  the  inter- 
vening space,  the  eariti/  of  the  pelvis.  The  parts  forming  the  brim  do 
not  all  lie  in  one  plane,  the  promontory  rising  alcove  the  remainder 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


139 


of  the  linea  terminalis.  This  inlet  has  in  the  white  woman  somewhat 
the  shape  of  a  rounded-off  heart  on  playing-cards.  It  is  16  inches  in 
circumference.  Four  distances,  so-called  diameters,  are  measured  in 
it ;  the  anteroposterior  diameter,  also  called  the  true  conjugate,  is  the 
distance  from  the  middle  of  the  promontory  to  the  upper  end  of  the 
symphysis  pubis,  which  is  4J  inches  (eleven  centimetres).  On  account 
of  the  mobility  of  the  sacrum,  this  measure  is,  however,  variable. 
When  the  legs  are  stretched  out,  it  becomes  four  millimetres  (^  inch) 
longer  than  when  they  are  flexed  on  the  abdomen,  a  point  that  may 
be  used  to  advantage  if  the  pelvis  is  somewhat  small  in  comparison 

Fig.  176. 


The  pelvic  inlet.  A  iJ,  anteroposterior  or  true  conjugate  diameter  ;  C  L>,  left  oblique  diameter  ; 
E  F,  riglit  oblique  diameter ;  6  H,  transverse  diameter  ;  A  S,  sacrocotyloid  distance  ;  /  K,  crest  of 
the  ilium. 

with  the  head  of  the  child.  It  may  also  be  used  in  examining  the 
relative  proportion  between  head  and  pelvis ;  by  alternately  stretch- 
ing and  flexing  the  thighs  we  can  make  the  head  move  up  and  down. 
The  oblique  diameter  goes  from  the  iliosacral  joint  on  one  side  to  the 
iliopectineal  eminence  on  the  other,  and  measures  5  inches  (twelve 
and  three-quarters  centimetres).  The  transverse  diameter  is  situated 
between  the  two  points  of  the  iliopectineal  line  which  are  farthest 
separated  from  each  other  and  measures  5J  inches  (thirteen  and  one- 
half  centimetres)  (Fig.  176).  Finally,  we  distinguish  the  sacrocotyloid 
distance,  drawn  from  the  middle  of  the  promontory  to  the  point  on 
the  iliopectineal  line  where  it  is  crossed  by  a  line  drawn  at  right 
angles  with  it  through  the  middle  of  the  acetabulum.     This  distance 


140 


NORMAL   LABOR. 


is  normally  about  3J  inches  (from  eight  and  three-quarters  to  nine 
centimetres).  The  oblique  diameters  are  designated  as  right  and  left 
according  to  their  posterior  end.  The  right  is  a  little  longer  than  the 
left,  and,  on  the  other  hand,  the  right  sacrocotyloid  distance  is  shorter 
than  the  left,  a  difference  due  to  the  greater  use  made  of  the  right  leg 
by  which  this  side  is  pressed  inward. 

The  upper  end  of  the  symphysis  being  turned  outward,  the  true 
conjugate  does  not  give  the  shortest  distance  between  the  promon- 
tory and  the  symphysis.  This  is  found  between  the  centre  of  the 
promontory  and  a  point  on  the  j)osterior  surface  of  the  symphysis 

Fig.  177. 


The  pelvic  outlet. 


situate  from  one-quarter  to  one-half  inch  lower  down,  and  may  be  as 
much  as  one-half  incli  shorter  than  the  true  conjugate.  This  distance 
is  called  the  obstetrical,  minimum,  or  available  conjugate,  and  measures 
only  4  inches  (ten  centimetres). 

The  outlet,  or  the  inferior  strait  (Fig.  177),  may  be  regarded  as 
composed  of  an  anterior  and  a  posterior  triangle  touching  each  other 
by  their  bases.  It  is  limited  by  the  subpubic  ligament  in  front,  the 
apex  of  the  coccyx  behind,  the  tuberosity  of  the  ischium,  the  ascend- 
ing ramus  of  the  ischium,  the  descending  ramus  of  the  pubes,  and  the 
sacrosciatic  ligaments  on  the  sides.  Two  diameters  are  taken  in  it,  the 
anteroposterior  from  the  lower  end  of  the  symphysis  to  the  tip  of  the 
coccyx,  which  measures  3|  inches  (nine  and  one-half  centimetres),  and 
the  transA^erse  from  one  tuberosity  of  the  ischium  to  the  other,  which 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL.       141 

is  4 J  inches  (eleven  centimetres)  long;  but,  since  during  the ' child- 
bearing  age  the  coccyx  normally  is  movable  and  recedes  during  labor, 
the  real  distance  that  has  to  be  considered  is  that  from  the  lower  end 
of  the  symphysis  to  the  apex  of  the  sacrum,  which  is  4^  inches  (eleven 
and  one-half  centimetres).  There  is  no  oblique  diameter  in  the  out- 
let of  the  bony  pelvis,  but  when  the  sacrosciatic  ligaments  are  in  place, 
the  oblique  diameter  is  taken  from  the  middle  of  these  ligaments  to 
the  juncture  of  the  ascending  ramus  of  the  ischium  and  the  descend- 
ing ramus  of  the  pubes.  It  measures  4J  inches  (eleven  and  one-half 
centimetres).  The  circumference  is  13 J  inches  (thirty-four  centi- 
metres). 

The  cavity,  as  a  whole,  is  curved,  with  concavity  turned  forward. 
It  is  widest  in  a  plane  which  may  be  supposed  to  go  through  the  mid- 
dle of  the  symphysis  pubis,  the  connection  between  the  second  and 
third  sacral  vertebrae,  and  the  acetabula.  In  this  plane  the  anteropos- 
terior diameter  measures  5  inches  (twelve  and  three-quarters  centi- 
metres), and  the  transverse  a  little  less  than  5  inches  (twelve  and 
one-half  centimetres). 

The  narrow^est  part  of  the  canal  is  a  plane  supposed  to  be  laid 
between  the  lower  border  of  the  subpubic  ligament,  the  lower  end  of 
the  sacrum,  and  the  spine  of  the  ischium  on  both  sides.  In  this  nar- 
rowest plane  of  the  pelvic  canal  the  anteroposterior  diameter  measures 
4J  inches  (eleven  and  one-half  centimetres),  and  the  transverse  from 
4  to  4^  inches  (ten  and  one-half  centimetres). 

The  pelvic  canal  is  much  shorter  in  front  than  behind,  the  sym- 
physis measuring  only  If  inches  (four  and  one-half  centimetres),  the 
distance  from  the  promontory  to  the  apex  of  the  coccyx  about  6 
inches  (fifteen  centimetres)  along  the  bones  and  5  inches  (twelve  and 
three-quarters  centimetres)  in  the  air-hne.  On  the  sides  the  distance 
from  the  linea  terminalis  to  the  tuberosity  is  3|  inches  (nine  centi- 
metres). 

The  ascending  ramus  of  the  ischium  and  the  descending  ramus  of 
the  pubes  form  with  those  of  the  opposite  side  an  angle,  the  jjubic  arch, 
which  is  from  ninety-five  to  one  hundred  degrees,  and  is  rounded  out 
by  the  subpubic  ligament. 

The  side  walls  of  the  true  pelvis,  formed  by  the  ilium  and  the 
ischium,  offer  a  smooth  bony  surface,  which  in  the  erect  position  is 
slightly  concave  in  an  anteroposterior  line  and  slopes  down  to  the 
outlet.  A  line  drawn  from  the  spine  of  the  ischium  to  the  iliopubic 
eminence  divides  it  into  an  upper  and  a  lower  portion  of  nearly  equal 
size.  This  hollow  inclined  plane  exercises  much  influence  on  the 
rotation  of  the  head  during  labor. 

§  4.  Inclination  and.  Axes  of  the  Pelvis  (Fig.  178). — Unlil  the 
beginning  of  the  nineteenth  ctjntury  the  position  of  the  i)elvis  iu  the 


142 


NORMAL   LABOR. 


body  was  not  understood.  The  symphysis  pubis  was  supposed  to 
point  nearly  forward,  a  misconception  whicli  is  preserved  till  this  day 
in  the  name  horizontal  branch  often  given  to  the  upper  branch  of  the 
pubes,  while  in  reality  it  ascends.  When  attention  was  directed  to 
the  fact  that  the  pelvis  has  a  much  more  inclined  position  than  was 
formerly  believed,  greater  importance  was  attributed  to  this  inclina- 
tion than  it  deserves  from  an  obstetric  stand-point.  This  inclination 
of  the  pelvis  to  the  horizon  is  very  variable,  and  depends  much  on 
the  position  of  the  lower  extremities.  It  is  smallest  (from  40  to  50 
degrees)  when  the  thighs  are  moderately  separated  and  slightly  rotated 

Fig.  178. 


The  inclination  of  the  pelvis.  (Tarnier  and  Chantreuil,  1.  c.)  A,  promontory  ;  P,  upper  end  of 
symphysis  pubis ;  C,  apex  of  coccyx  ;  C,  apex  of  coccyx  driven  back  ;  X,  lower  end  of  symphysis 
pubis.  A  P,  true  conjugate  diameter  ;  A  I,  minimum^  conjugate  of  inlet ;  A  L,  diagonal  conjugate  ; 
JVC,  axis  of  inlet;  AR,  axis  of  outlet;  V R' ,  axis  of  outlet  when  coccyx  is  pushed  back;  HO, 
horizontal  line. 


inward.  It  is  increased  by  bringing  the  knees  together  or  separating 
them  more,  by  increased  rotation  inward,  or  by  rotation  outward,  and 
may  reach  100  degrees.  In  the  common  erect  position  it  is  about 
45  degrees.  In  order  to  give  a  pelvis  the  right  direction,  it  should  be 
held  so  that  the  anterior  superior  spine  of  the  ilium  lies  in  one  per- 
pendicular plane  with  the  spine  of  the  pubes,  and  the  cotyloid  notch 
points  almost  straight  downward. 

The  inclination  of  the  outlet  varies,  of  course,  with  that  of  the 
inlet.  In  the  erect  position  the  outlet  points  backward,  forming  with 
the  horizon  a  small  angle ;  but  when  the  coccyx  is  pushed  back,  the 
outlet  becomes  horizontal  or  is  even  directed  slightly  forward. 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


143 


When  a  person  stands  upright,  the  centre  of  gravity  is  behind  a 
Kne  uniting  the  centre  of  the  acetabula,  and  the  upper  part  of  the 
body  would,  therefore,  fall  backward  if  the  pelvis  were  not  held  for- 
ward by  the  strong  iliofemoral  ligament  extending  from  the  anterior 
inferior  spine  and  adjacent  parts  of  the  ilium  to  the  anterior  inter- 
trochanteric line  of  the  femur. 

To  facilitate  the  comprehension  of  the  form  of  the  pelvic  cavity, 
several  lines  are  drawn  which  are  called  the  axes.  The  axis  of  the 
inlet — that  is,  a  line  drawn  perpendicularly  through  tlie  centre  of  the 
conjugate — reaches  the  tip  of  the  coccyx  below  and  the  umbilicus 
above.  The  axis  of  the  outlet  is  a  line  drawn  at  right  angles  from  the 
middle  of  the  anteroposterior  diameter.  It  strikes  the  promontory, 
but  when  the  coccyx  is  driven  back,  this  line  strikes  the  lower  end  of 


Fig.  179. 


The  axis  of  the  pelvis. 


A,  promontory  ;  B,  apex  of  coccyx  ;  C,  symphysis  pubis ;  D,  crossing  point ; 
E,  axis  of  the  pelvis ;  F  G,  horizontal  line. 


the  first  sacral  vertebra.  The  axis  of  the  j^elvis  does  not  correspond 
to  any  regular  mathematical  curve.  It  is  an  irregular  one  obtained 
by  tlie  following  construction.  A  line  is  drawn  from  the  promontory 
to  the  upper  end  of  the  symphysis,  another  from  the  tip  of  the  coccyx 
to  the  low^er  end  of  the  symphysis.  Both  are  prolonged  in  front  of 
the  symphysis  until  they  meet  each  other,  and  from  the  point  of  inter- 
section numerous  equidistant  straight  lines  are  drawn  to  the  median 
line  of  the  sacrum  and  the  coccyx.  Finally,  each  of  these  lines  be- 
tween the  symphysis  and  the  sacrum  and  coccyx  is  divided  into  two 
equal  parts  and  aline  is  drawn  through  all  the  mid-points.  This  is  the 
axis  of  the  pelvis.  Since  the  symphysis  and  the  two  upper  sacral 
vertebrae  present  practically  parallel  surfaces,  the  upper  part  of  the 


144  NORMAL    LABOR. 

pelvic  axis  is  nearly  straight,  while  the  lower  approaches  a  circle 
drawn  with  the  lower  end  of  the  symphysis  as  centre.  The  symphysis 
forms  with  the  true  conjugate  an  angle  of  about  100  degrees. 

§  5.  Differences  between  the  Male  and  the  Female  Pelvis. — 
The  female  pelvis  is  lower  and  wider  than  the  male.  The  bones,  cor- 
responding to  the  weaker  muscles,  are  lighter  and  more  delicate  in 
contour.  The  iliac  fossa  lies  more  horizontally.  The  distance  between 
the  crests  of  the  ilium  is  wider.  The  sacrum  is  more  curved,  wider, 
and  less  projecting.  Both  the  transverse  and  the  anteroposterior 
diameters  are  longer.  The  pubic  arch  is  wider, — from  95  to  100 
degrees,  while  in  man  it  is  only  from  70  to  75  degrees.  The  lower 
edges  of  the  ascending  ramus  of  the  ischium  and  the  descending 
ramus  of  the  pubes  are  turned  more  outward.  The  pubic  portion  of 
the  iliopectineal  line  is  less  sharp,  and  the  posterior  surface  of  the 
ascending  branch  of  the  pubes,  as  Avell  as  the  symphysis,  more  con- 
vex, so  as  to  facilitate  the  entrance  of  the  head  into  the  pelvic  cavity. 
The  obturator  foramen  is  more  oval,  in  man  more  triangular.  The 
tuberosities  of  the  ischium  are  more  widely  separated  from  each  other. 
The  acetabula  look  more  forward.  The  distance  from  one  trochanter 
to  the  other  is  greater,  and  the  thigh-bones  slant  more  inward  towards 
the  knees. 

These  sexual  differences  are  congenital,  but  become  more  promi- 
nent after  puberty,  the  pelvis  during  childhood  being  nearer  the  male 
type  in  both  sexes. 

§  6.  The  Pelvis  of  the  New-born. — The  pelvis  of  the  new-bom 
child  (Fig.  180)  differs  considerably  from  that  of  the  adult  woman. 
It  is  not  only  smaller,  but  also  of  a  different  shape.  The  five  sacral 
vertebrae  are  separated,  and  the  innominate  bone  is  composed  of 
three  separate  bones  meeting  in  the  acetabulum.  The  promontory  is 
less  marked  and  stands  higher  over  the  rest  of  the  linea  terminalis. 
The  sacrum  is  straighter.  Its  alse  are  narrower.  The  ascending 
branch  of  the  pubes  is  markedly  shorter.  The  pubic  arch  forms  in 
both  sexes  an  acute  angle.  The  distance  between  the  anterior  su- 
perior spines  of  the  ilia  is  nearly  as  great  as  that  between  the  crests. 
The  iliac  bones  take  a  more  perpendicular  course.  The  walls  of  the 
cavity  slope  more  down  towards  the  outlet.  The  brim  is  more  round. 
Upon  the  whole,  the  pelvis  in  childhood  comes  nearer  to  the  male 
type  (Fig.  181). 

The  change  from  the  infantile  to,  the  adult  pelvis  is  due  partly  to 
an  innate  disposition,  partly  to  the  development  of  the  uterus  that 
takes  place  at  puberty,  but  chiefly  to  the  weight  of  the  upper  part 
of  the  body,  pressure  of  the  inferior  extremities,  tension  of  the  pelvic 
ligaments,  and  pull  exercised  by  muscular  contraction.  The  weight 
of  the  superposed  body  presses  the  sacrum  forward  and  downward, 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


145 


which  will  make  the  promontory  jut  more  into  the  brim  of  the  pelvis 
and  bring  it  lower  down.  The  weight  falling  more  on  the  median 
parts  than  on  the  alte,  the  lateral  concavity  becomes  smaller,  at  the 


Fig.  180. 


A 
Pelvis  of  a  new-born  child.    A,  front  view  after  removal  of  the  anterior  wall ;  B,  side  view  after 
perpendicular  section  in  median  line  ;  C,  the  brim.      1,  lumbar  part  of  the  vertebral  column;  2, 
promontory  ;  .3,  sacrum  ;  3',  coccyx  ;  4,  ilium  ;  5,  ischium  ;  6,  pubes.    A  P,  anteroposterior  diameter; 
O  O,  oblique  diameters ;  T  T,  transverse  diameter. 

same  time  that,  by  combined  pressure  from  above  and  resistance  exer- 
cised by  the  sacrosciatic  ligaments,  the  concavity  from  above  down- 
ward increases.     A  similar  action  is  exercised  by  the  symphysis  pubis 

10 


146 


XORMAL    LABOR. 


and  the  sacro-iliac  ligaments,  tlie  result  of  which  is  that  the  iliac  por- 
tion of  the  linea  iliopectinea  becomes  more  bent,  that  tlie  transverse 


Fig.  181. 


Pelvis  of  child.     CWood's  Museum,  Bellevue  Hospital,  No.  180,  one-third  actual  size.) 

diameters  of  the  pelvis  increase,  and  the  pelvic  brim  approaches  more 
an  elliptical  shape  (Figs.  182,  183). 

In  standing,  walking,  rmming,  or  making  other  movements  with 
the  lower  extremities,  the  heads  of  the  femora  are  pressed  against 
the  acetabula,  and  thus  con- 

trilDute   to   the    curvature    of  Fig.  183. 

the  linea  terminalis. 

Fig.  182. 


Diagram  of  a  section  of  the  pelvis 
of  the  new-bom.    (Schroeder.) 


Diagram  of  a  section  of  the  pelvis  of  an  adult  woman. 
(Schroeder.) 


§  7.  Differences  of  the  Pelvis   in   Different  Races. — From  an 
anthropological  stand-point  four  different  forms  are  distinguished  :  (1) 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL.       147 

the  heart-shaped,  (2)  the  ehiptical  with  longest  transverse  diameter, 
(3)  the  circular,  and  (4)  the  elliptical  with  longest  anteroposterior 
diameter.  The  first  is  the  one  found  in  white  women  and  wliich  we 
have  described  above.  Indians,  Javanese,  and  the  Australian  negresses 
have  a  more  round  pelvis.  That  of  the  African  negress  is  more  like 
that  of  the  Caucasian  race,  while  Hottentots  and  Bushwomen  have 
pelves  in  which  the  anteroposterior  diameters  are  longer  than  the 
transverse. 

These  racial  peculiarities  often  give  rise  to  hard  labors  when  the 
parents  belong  to  different  races, — for  instance,  in  Greenland,  when 
European  sailors  have  intercourse  with  Eskimo  women. 

Independently  of  these  racial  differences,  we  may  even  suppose 
that  childbirth  in  general  has  undergone  a  change  in  the  whole 
civilized  world.  In  the  beginning  woman  had  probably  not  more 
difficulty  in  giving  birth  to  her  children  than  animals  in  bringing  forth 
their  young  ones,  but  with  increasing  mental  development  and  hered- 
itary influences  the  heads  doubtless  became  larger,  while  the  pelves 
retained  their  old  proportions.  That  heredity  also  plays  a  role  in  the 
shape  of  the  pelvis  is  proved  by  numerous  observations  in  obstetric 
practice,  of  cases  in  which  daughters  present  the  same  pelvic  peculiar- 
ities as  their  mother. 

B.    The  Soft  Parts  of  the  Parturient  Canal. 

§  1.  Muscles. — The  outlines  of  the  bony  pelvis  become  modified 
by  the  addition  of  muscular  layers  which  form  a  padding  to  the  hard 
bony  surfaces  or  by  their  bulk  diminish  the  available  space.  Thus 
the  iliac  fossa  is  lined  by  the  flat  iliacus  muscle,  which  blends  with 
the  thick,  fusiform  j^soas  magnus  (Fig.  184).  The  latter  encroaches 
on  the  superior  strait  in  front  of  the  sacro-iliac  joint  and  along  the 
iliac  portion  of  the  ihopectineal  line. 

The  pyr if ornus  (Fig.  185)  is  a  fan-shaped  muscle  arising  from  the 
anterior  surface  of  the  sacrum  and  nearly  filling  the  great  sacrosciatic 
foramen.     It  forms  a  padding  for  the  posterior  wall  of  the  pelvis. 

In  front  the  pelvis  is  lined  by  the  obturator  internus,  which  arises 
from  the  obturator  membrane  and  adjoining  bones  (Fig.  186)  and 
passes  out  through  the  lesser  sacrosciatic  foramen. 

The  perineal  muscles  (Fig.  187)  nearly  close  the  outlet  of  the  pelvis. 
In  the  urogenital  triangle  there  are  three  pairs  of  small  muscles,  situ- 
ated between  the  superficial  perineal  fascia  and  the  anterior  layer  of 
the  deep  perineal  fascia, — namely,  the  ischiocavernosus,  or  erector  cli- 
toridis  muscle^  the  bulbocavernosus,  or  sphincter  vagince  muscle,  and  the 
superficial  transversus  perincei  muscle.  They  are  of  importance  chiefly 
for  the  role  they  play  in  copulation.  The  ischiocavernosus  muscle 
compresses  the  corpus  cavernosum  of  the  clitoris.     The  bulbocaver- 


148 


NORMAL   LABOR. 


nosus  muscle  presses  on  the  vulvovaginal  bulb.  In  joint  action  they 
cause  erection  of  the  clitoris.  The  bulbocavernosus  also  presses  on 
the  vulvovaginal  gland  and  thus  contributes  to  the  lubrication  of  the 
parturient  canal.    The  transversus  perinsei  muscle  helps  to  steady  the 


Fig.  184. 


The  pelvis  covered  -with  muscles.  (Tarnier  and  Chantreuil,  1.  c.)  A,  the  aorta;  B,  the  left 
common  iliac  artery  ;  C,  the  left  external  iliac  artery  ;  J),  the  origin  of  the  left  internal  iliac  artery  ; 
E,  vena  cava  inferior ;  F,  the  left  common  iliac  vein  ;  6,  the  left  external  iliac  vein  ;  H,  the  attach- 
ment of  the  sacrosciatic  ligaments  on  the  sacrum ;  the  dark  mass  above  is  the  origin  of  the  pyri- 
formis  muscles  on  the  sacrum  ;  /,  promontory  ;  J,  quadratus  lumborum  muscle ;  A',  psoas  magnus 
(the  psoas  parvus  lies  in  front  of  it) ;  i,  iliacus  ;  31.  obturator  externus  ;  jY,  the  pubic  arch  ;  0,  the 
large  trochanter  ;  P,  section  through  the  muscles  of  the  anterior  abdominal  wall. 


perineal  body  and  push  the  presenting  part  of  the  foetus  forward 
during  parturition. 

In  the  anal  region  we  find  the  sjjhincfer  cini  exiernus. 

The  deep  muscles  of  the  genito-urinary  region  are  small  and 
hardly  of  importance  from  an  obstetric  stand-point.  In  the  anal 
region  we  have  the  internal  sphincter  ani,  the  levator  ant  muscle,  and 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


149 


the  coecygeus.       Of  these  the  first  is  only  a  thicl^er  portion  of  the 
circular  layer  of  the  rectum,  situated  inside  of  the  external  sphincter. 


Fig.  185. 


The  posterior  wall  of  the  pelvic  cavity,  with  the  pyriformis  muscles  and  the  sacro-iliac  liga^ 
ments.  (Tarnier  and  Chantreuil,  1.  c. )  C,  coccyx  ;  O,  great  sacroseiatic  ligament ;  L,  lesser  sacro- 
sciatic  ligament ;  P,  pyramidalis  muscle  ;  .S,  the  first  sacral  vertebra. 

The  levator  ani  muscle  (Fig.  188),  on  the  contrary,  forms  an  important 
part  of  the  pelvic  floor,  and  is  of  considerable  interest  from  an  obstet- 

FiG.  186. 


Side  view  of  the  pelvic  cavity,  showing  the  obtu:  ator  internus  muscle  and  tlie  sacroseiatic  ligar 
ments.  (Tarnier  and  Chantreuil,  1.  c.)  G,  the  great  sacroseiatic  ligament;  L,  the  lesser  sacro- 
seiatic ligament;  0,  the  obturator  internus  muscle;  P,  symphysis  pubis;  S,  union  of  the  first  and 
second  sacral  vertebrae. 

ric  stand-point.     It  is  a  horseshoe-shaped  muscular  expansion,  which 
together  with  the  coecygeus  forms  the  pe/ric  diaphragm.     It  is  open  in 


150 


NORMAL   LABOR. 


front,  and  forms  a  double  loop  behind  the  vagina  and  the  rectum. 
The  levator  ani  and  the  coccygeus  touch  each  other  at  their  edges, 
so  that  one  is  a  continuation  of  the  other,  and  often  they  even  coa- 
lesce.   The  levator  ani  arises  from  the  posterior  surface  of  the  body  of 


Fig.  187. 


The  muscles  of  the  perineum.  (Breisky.)  1,  glans  clitoridis;  2,  corpus  clitoridis;  3,  meatus 
urinarius ;  4,  tendon  of  the  ischiocavernosus  muscle  ;  5,  bulb ;  6,  ischiocavernosus  muscle ;  7,  vaginal 
entrance;  8,  sphincter  vaginae,  or  bulbocavernosus  muscle;  9,  fossa  navicularis;  10,  Bartholin's 
gland ;  11,  superficial  transversus  perinsei  muscle ;  12,  anus ;  13,  sphincter  ani  externus ;  14,  15, 
levator  ani  muscle ;  16,  coccygeus  muscle ;  17,  great  sacrosciatic  ligament ;  18,  obturator  internus 
muscle ;  19,  glutseus  maximus ;  20,  os  coccygis. 

the  pubic  bone,  from  a  point  near  the  spine  of  the  ischium,  and  from 
the  tendinous  arch  of  the  pelvic  fascia  suspended  between  the  two 
bony  starting-points.  Some  loops  go  from  side  to  side  between  the 
vagina  and  the  rectum,  but  the  greater  part  goes  behind  the  intestine, 
hugging  the  concavity  of  its  end-curve  and  supporting  it  from  below 
(Fig.  189).  Some  fibres  are  inserted  on  the  fourth  vertebra  of  the 
coccyx.     The  coccygeus  arises  from  the  spine  of  the  ischium  and  the 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


151 


lesser  sacrosciatic  ligament.     It  spreads  fan-like,  and  is  inserted  over 
the  upper  part  of  the  coccyx  and  the  last  two  sacral  vertebrae. 

Together  with  the  two  fasciae  that  invest  its  upper  and  lower 
surface — the  rectovesical  and  the  anal  fascia — the  pelvic  diaphragm 
forms  a  strong  sheet  on  which  rest  the  uterus  and  the  bladder.  This 
muscle  lifts  the  rectum  upward  during  defecation  and  draws  the  anus 
forward  in  the  direction  of  the  symphysis.  During  childbirth  it  pulls 
the  vagina  upward  and  pushes  the  child  forward  so  as  to   make  it 

Fig.  188. 


The  levator  ani  muscle  seen  from  below.     (Dickinson.)    The  cut  ends  projecting  inward  are  those 
which  run  into  the  rectovaginal  septum. 


turn  around  the  pubic  arch.  It  may  also  act  as  a  sphincter  of  the 
vagina,  and  it  draws  the  apex  of  the  coccyx  forward. 

§  2.  The  Fasciae  of  the  Perineum  (Fig.  190). — The  urogenital 
region  of  the  perineum  has  under  the  skin  a  layer  of  adipose  tissue 
interspersed  with  fibrous  tracts.  Under  that  is  found  a  sheet  of  dense 
connective  tissue  called  the  superficial  pei^'meal  fascia.  Under  this  lies 
the  deep  perineal  fascia.,  or  triangular  ligament,  which  has  two  layers, 
a  superficial  and  a  deep.  The  superficial  layer  is  at  the  sides  attached 
to  the  ascending  ramus  of  the  ischium  and  the  descending  ramus 
of  the  pubes,  and  in  front  to  the  transverse  ligament  of  the  pelvis. 
Behind,  this  superficial  layer  of  the  deep  fascia  blends  with  the  deep 
layer  of  the  superficial  fascia  and  with  the  deep  layer  of  the  deep 
fascia. 

The  deep  layer  of  the  deep  fascia  is  likewise  fastened  to  the  rami 
of  the  pubes  and  the  ischium.     In  front  it  covers  the  anterior  portion 


152 


NORMAL    LABOR. 


of  the  levator  ani  muscle.  Behind,  it  is  continued  as  a  dense  fascial 
sheet  covering  the  remainder  of  the  lower  surface  of  the  levator  ani 
muscle,  and  called  the  anal  fascia. 

The  deep  perineal  fascia,  as  well  as  the  rectovesical  fascia,  is  per- 
forated by  the  urethra  and  the  vagina. 

Fig.  189. 


Side  view  of  the  levator  ani  muscle.     (Lusehka.)    The  ischium  has  been  removed,    i,  levator  ani ; 
C,  coccygeus,  faintly  indicated. 


Where  the  superficial  perineal^  fascia  and  the  two  layers  of  the 
deep  perineal  fascia  blend,  at  the  posterior  margin  of  the  superficial 
transversus  perinsei  muscle,  they  are  fortified  by  the  ischioperineal 
ligament,  which  forms  the  boundary-line  between  the  urogenital  and 
the  anal  regions. 

By  all  these  ligaments  the  pelvic  bones  are  strongly  bound  to- 
gether, and  the  soft  parts  prevented  from  too  large  excursions,  so  as 
to  form  a  solid  canal  for  the  passage  of  the  child. 


THE  ANATOMY  OF  THE  PARTURIENT  CANAL. 


153 


The  inside  of  the  pelvis  is  covered  by  the  pelvic  fascia,  and  inner- 
most the  peritoneum.  The  spaces  between  the  organs  are  filled  with 
loose  connective  and  adipose  tissue,  and  since  the  uterus  itself,  towards 
the  end  of  pregnancy  and  during  labor,  descends  into  the  pelvic  cavity, 
its  walls  also  diminish  the  lumen  of  the  pelvic  canal. 

Besides  the  soft  parts  lining  the  pelvis,  the  parturient  canal  is  com- 
posed of  the  uterus,  the  vagina,  and  the  vulva. 

Fig.  190. 


Pelvic  and  perineal  faseiEe.  (Dickinson.)  Shows  how  the  levator  ani  muscle  is  strengthened 
by  dense  sheets  of  fibrous  tissue :  1,  superficial  perineal  fascia,  superficial  layer,  or  subcutaneous 
adipose  tissue ;  2,  superficial  perineal  fascia,  deep  layer,  or  superficial  perineal  fascia  proper ;  3, 
triangular  ligament,  or  deep  perineal  fascia,  superficial  layer;  4,  triangular  ligament,  or  deep 
perineal  fascia,  deep  layer  ;  5,  vesicorectal  fascia  (a  part  of  the  pelvic  fascia). 


§  3.  The  Uterus.  The  Lower  Uterine  Segment. — In  an  earlier 
part  of  this  work  we  have  described  the  changes  the  uterus  undergoes 
during  pregnancy.  When  labor  begins,  the  uterus  is  divided  into  an 
upper  active  part  and  a  lower  passive  part.  This  latter  is  called  the 
loicer  uterine  segment,  and  the  line  of  demarcation  the  contraction  ring 
(Figs.  191,  192). 

This  ring  is  situated  where  externally  the  peritoneum  cannot 
easily  be  separated  from  the  uterus,  and  where  in  the  wall  of  the 
uterus  lies  the  large  coronal  vein.  In  Braune's  celebrated  plate 
(Fig.  205)  it  is  marked  as  being  the  internal  os,  but  that  is  a  mistake, 
microscopical  examination  having  shown  that  the  decidua  continues 
one  and  a  half  inches  (four  centimetres)  below  the  contraction  ring. 


154 


NORMAL   LABOR. 


Under  the  point  where  the  decidual  layer  ceases  the  plicee  palmatae 
of  the  cervix  with  columnar   epithelium  are  found,  and  below  the 


Diagram  of  the  genital  canal  before  the 
beginning  of  labor  in  a  pluripara.  (Schroe- 
der.)  CR,  contraction  ring;  o.i,  internal 
OS ;  o.e,  external  os. 


Fig.  193. 


Fig.  194. 


ILlliMl 


i(m] 


Fig   192. 


Diagram  of  the  genital  canal  after  the 
dilatation  of  the  lower  uterine  segment  and 
the  cervical  canal.  (Schroeder.)  Lettering 
same  as  in  Fig.  191. 


Dec.  Ch.\Amn. 

Fig.  193.— Section  through  the  boundary  of 
the  ovum,  the  lower  uterine  segment,  tlie  cervix, 
and  the  upper  part  of  the  vagina.  Nine-tenths 
natural  size.  (Chiari.)  1,  boundary -line  of  in- 
sertion of  the  ovum  ;  V.c,  coronal  vein  ;  2,  utero- 
vesical  pouch  of  the  peritoneum  ;  V.a..  bladder ; 
between  3,  which  simulates  the  external  os,  and 
4,  tesselated  vaginal  epithelium ;  from  4  to  .5, 
cervix  with  plica?  palmatte  and  columnar  epithe- 
lium (the  cilia  lost)  ;  from  1  to  5,  covered  with 
a  thin  layer  of  decidua. 

Fig.  194. — Boundary-line  of  the  insertion  of 
the  ovum,  enlarged  ten  times,  showing  folding 
of  the  decidua  and  chorion. 


cervix  the  vagina  with  pavement  epithelium  (Fig.  193).     The  micro- 
scope has  furthermore  revealed  that  the  white  line  which  to  the  naked 


THE  ANATOMY    OF   THE    PARTURIENT    CANAL. 


155 


eye  marks  the  boundary-line  of  the  insertion  of  the  ovum  to  the  uter- 
ine wall  is  due  to  a  peculiar  folding  of  the  chorion  and  the  decidua 
(Fig.  194). 

The  contraction  ring  is  felt  by  internal  examination  of  the  uterus, 
and  can  sometimes  also  be  felt  by  abdominal  palpation,  and  in  cases 
of  mechanical  disproportion  between  the  fetal  head  and  the  pelvis 
it  may  even  be  visible.  In  dead  bodies  it  is  less  marked,  because 
muscular  contraction  ceases. 

§  4.  The  Cervix,  the  Vagina,  and  the  Vulva. — The  cervix,  the 
vagina,  and  the  vulva  have  during  pregnancy  become  so  softened  and 

Fig.  195. 


The  parturient  canal.  (Hodge.)  a,  the  upper  end  of  the  symphysis  pubis ;  6,  the  promontory : 
c,  the  lower  end  of  the  symphysis,  d,  the  situation  of  the  apex  of  the  coccyx  before  it  is  pushed 
back  ;  X,  the  axis  of  the  pelvis. 


enlarged  that  they  can  let  the  foetus  pass,  for  which  purpose  also  space 
is  gained  by  the  unfolding  of  the  plicae  palinatse  and  the  labia  minora; 
but  the  perineum  becomes  enormously  distended,  so  that  its  median 
line,  which  in  the  unimpregnated  state  measures  only  three-quarters 
of  an  inch,  when  distended  by  the  head  may  be  five  or  six  inches 
long.  By  this  elongation  the  soft  parts  of  the  genital  canal  form  a 
continuation  of  the  pelvic  cavity,  and  the  vulva  turns  more  forward 
(Fig.  195). 

The  points  of  the  canal  that  before  labor  are  narrowest  undergo, 
of  course,  greater  tension  and  are  most  liable  to  tear, — namely,  the 
external  os,  the  entrance  to  the  vagina,  and,  in  a  lesser  degree,  the 
rinia  pudendi  formed  behind  by  the  thin  frci?nulum. 


156 


NORMAL    LABOR. 


CHAPTER    MI. 
THE    FETAL    HEAD. 

After  having  studied  tlie  canal  tlirough  which  the  foetus  is  ex- 
pelled, we  shall  turn  our  attention  to  the  object  that  is  to  be  expelled, 
and  particularly  the  head  of  the  foetus  as  the  least  yielding  part. 

The  head,  as  a  whole,  is  a  spheroid  body  (Figs.  196-199).  The 
face  is  small  and  triangular.  The  skull  is  composed  of  a  number  of 
bones  wdiich  are  united  by  fibrous  or  cartilaginous  tissue.     There  are 

Fig.  196. 


Fetal  head,  front  view.    Actual  size.    A-A\  bitemporal  diameter. 

two  frontal  bones  and  tiro  parietal  bones.  The  later  occipital  bone 
consists  of  four  pieces — a  basilar  portion,  two  condylar  portions,  and 
an  upper  tabular  portion  which  shows  fissures  between  the  four  parts 
of  which  it  was  composed  at  an  earlier  period  of  development.  The 
temporal  bone  consists  of  three  pieces — the  squamozygomatic,  the  tym- 
panic,  and  the  petromastoid.  The  great  wings  of  the  sphenoid  bone 
are  still  separated  from  the  body  of  the  bone. 

The  lines  in  which  the  bones  touch  one  another  are  called  sutures. 
Between  the  two  frontal  bones  runs  the  frontal  suture  (Fig.  1 96) ;  be- 


THE    FETAL    HEAD. 


157 


tween  the  frontal  bones  and  tlie  parietal  bones  lies  the  coronal  suture 
(Fig.  197) ;  between  the  two  parietal  bones  is  the  sagittal  suture  (Fig. 
198);  between  the  parietal  and  the  occipital  bone  is  ihe  lambdoidal 


suture  (Fig.  199);  and  between  the  temporal  and  (he  parietal  bone 
the  .sfjuavious  suture  (Fig.  197). 

On  the  top  of  the  head,  between  the  frontal  and  the  parietal  bones, 
is  found  a  large  opening — the  large  or  anterior  fontanelle — covered 
only  by  a  fibrous  nienibrane  and  continuous  with  the  (bur  sutures 
separating  those  bones.     The  distance    across  the  nicinbrane   from 


158 


NORMAL   LABOR. 


bone  to  bone  is  IJ  inches,  but  the  anterior  triangle  is  much  larger 
than  the  posterior,  so  that  the  anterior  angle  becomes  smaller  and 
enters  deeper  between  the  frontal  bones  than  does  the  posterior  angle 
between  the  parietal  bones. 

The  point  where  the  parietal  bones  meet  the  occipital  is  called  the 
small  or  posterior  fontanelle,  but  here  is  no  opening,  only  a  blending 
of  the  sagittal  and  the  lambdoidal  sutures. 

Fig.  198. 


Fetal  head,  from  above.    Actual  size,    A-A^,  biparietal  diameter  ;  B-B^,  bitemporal  diameter. 


At  the  lower  posterior  angle  of  the  parietal  bone,  at  the  junction 
of  the  lambdoidal  and  sc|uamous  sutures,  and  at  the  lower  anterior 
angle,  where  the  coronal  suture  strikes  the  squamous,  are  lateral 
fontanelles  which  have  been  distinguished  as  fonficiiU  GasserL  The 
last  named  cannot  be  felt  during  labor,  but  the  tliree  others  are  of 
great  diagnostic  value,  as  will  be  seen  later.     The  large  fontanelle  is 


THE    FETAL    HEAD. 


159 


easily  distinguished  by  its  size  and  shape  and  its  connection  with  four 
sutures.  Tlie  posterior  is  the  one  most  frequently  felt  in  normal  labor 
and  is  recognized  by  the  junction  of  three  sutures,  one  of  which  leads 
to  the  upper  end  of  the  occipital  bone,  which  is  characterized  by  its 
even,  smooth,  hard,  convex  surface,  while  at  the  posterior  lateral  fon- 
tanelle,  which  is  felt  only  in  the  rare  ear  presentations,  and  where 
there  also  are  three  sutures,  we  feel  the  irregular,  rough  surface,  of  the 
mastoid  portion  of  the  temporal  bone.     Between  the  mastoid  portion 

Fig.  199. 


Fetal  head,  from  behind.    Actual  size.    A-A ',  biparietal  diameter. 


of  the  temporal  bone  and  the  tabular  and  condylar  portions  of  the 
occipital  bone  are  found  large  triangular  openings  closed  with  a  fibrous 
membrane,  which  are  continuous  with  the  suture  between  the  con- 
dyloid and  scfuamous  part  of  the  temporal,  forming  a  complete  hinge, 
which  contrU3utes  much  to  the  mobility  of  the  cranial  bones. 

The  sutures  and  fontanelles  are  not  only  necessary  for  the  adapta- 
tion of  the  head  to  the  parturient  canal,  but  also  of  great  importance 
in  allowing  a  healthy  development  of  the  child's  brain  after  birth. 
The  large  fontanelle  seems  even  to  grow  in  size  during  the  first  nine 
months  of  the  child's  life.  Then  it  remains  stationary  from  the  ninth 
to  the  twelfth  month.  After  that  it  decreases  slowly  and  is  finally 
closed  by  the  nineteenth  or  twentieth  month. ^ 

1  Thomas  Morgan  Roleli,  Ptedialricy.  Philiidclpliia,  1896,  j).  G4. 


160  NORMAL    LABOR. 

Dimensions  of  the  Fetal  Head. — In  order  to  understand  the 
mechanism  of  labor,  it  is  necessary  to  know  tlie  proportions  between 
the  dimensions  of  tlie  fetal  head  and  those  of  the  pelvis  studied  above. 
For  this  purpose  certain  distances  between  opposite  points,  so-called 
diameters,  and  the  circumference  of  the  head  in  certain  places  are 
measured. 

A.  Median  Diameters. — 

1.  The  occipitomental  diameter  (Fig.  197,  A-B)  is  the  distance  be- 
tween the  posterior  fontanelle  and  the  middle  of  the  chin,  and  is  b\ 
inches  (thirteen  and  a  half  centimetres). 

2.  The  occipitofrontal  diameter  (Fig.  197,  A—C)  extends  from  the  pos- 
terior fontanelle  to  the  frontal  suture  at  the  glabella,  and  measures 
4|  inches  (eleven  and  three-fourths  centimetres). 

3.  The  siiboccipitobregmcdic  diameter  is  taken  from  the  boundarj^- 
line  between  the  occiput  and  the  nape  of  the  neck  to  the  centre  of  the 
large  fontanelle, — that  is,  the  point  where  the  sagittal,  frontal,  and 
coronal  sutures  would  intersect  one  another. — and  measures  3|  inches 
(nine  and  one-half  centimetres). 

4.  The  trachelohregmatic  diameter,  from  the  junction  of  the  chin 
and  neck  to  the  centre  of  the  large  fontanelle,  is  also  3|  inches  (nine 
and  one-half  centimetres). 

5.  The  fro7itomental,  from  the  highest  point  of  the  forehead  to  the 
point  of  the  chin,  measures  3J  inches  (eight  centimetres). 

6.  The  perpjendicidar  line  from  the  posterior  end  of  the  large  fonta- 
nelle to  the  base  of  the  skull  at  the  anterior  margin  of  the  foramen 
measures  3f  inches  (nine  and  one-half  centimetres)  and  marks  the 
height  of  the  head. 

B.  The  TRANSVERSE  DIAMETERS  are — 

1.  The  bipjarietal  (Figs.  198,  A-A' ,  and  199,  ^-.4'),  from  one 
parietal  eminence  to  the  other,  measures  3J  inches  (nine  centimetres). 

2.  The  bitemporal  (Figs.  196,  A- A',  and  198,  £-B')  is  the  longest 
distance  from  side  to  side  on  the  coronal  suture,  and  measures  3 
inches  (eight  centimetres). 

The  longest  diameter,  or  onaximum  diameter,  is  not  always  the 
occipitomental ;  the  posterior  point  lies  mostly  in  the  sagittal  suture  a 
little  alDove  the  point  of  the  occiput,  and  sometimes  below  it  on  the 
tabular  portion  of  the  occipital  bone. 

All  these  measurements  are  subject  to  considerable  individual 
variations.  The  figures  given  in  centimetres  represent  the  averages 
found  by  Schroeder.  As  a  rule,  the  male  foetus  has  a  larger  head 
than  the  female. 

The  occipitomentcd  circumference  is  14  inches,  the  occipitofrontal 
12 J,  and  the  s-uboccipitobrcginatic  11. 

The  distance  from   one   shoulder  to  tlie   other — the   bi.mcromial 


CHIEF   FEATURES    OF    CHILDBIRTH.  161 

diameter — measures  4|  inches  (twelve  centimetres),  but  it  is  e-asily 
reduced  to  3|  inches  (nine  and  one-half  centimetres). 

The  articulation  between  the  condyloid  portions  of  the  occipital 
bone  and  the  atlas  allows  very  free  movements  in  an  anteroposterior 
direction,  so  that  the'  chin  may  be  pressed  against  the  sternum  or  the 
occiput  against  the  back,  while  it  allows  only  a  limited  lateral  excur- 
sion and  rotation. 

On  account  of  the  great  mobility  of  the  bones,  the  configuration  of 
the  head  can  change  considerably  in  passing  through  the  pelvic  cavity. 
Its  size  may  also  be  diminished,  the  cerebrospinal  fluid  escaping 
from  the  head  to  the  spinal  canal  and  the  blood  being  pressed  into 
the  body. 

Having  represented  the  actual  dimensions  of  the  skull  in  the  four 
preceding  illustrations  (Figs.  196-199),  the  author  has  in  this  place 
added  a  figure  (Fig.  200)  representing  the  actual  size  of  the  true 
pelvis.  By  comparing  it  with  the  former,  the  reader  is  enabled  to 
form  a  clear  idea  of  the  mechanical  problem  of  childbirth. 


CHAPTER    IV. 

CHIEF   FEATURES    OF    CHILDBIRTH. 

The  beginner  will,  I  think,  get  a  clearer  idea  of  the  way  in  which  a 
child  is  born  if,  before  entering  into  any  details  and  explanations,  I 
describe  the  chief  features  of  labor. 

First  there  is  a  precursory  stage,  extending  over  about  two  weeks, 
during  which  the  uterus  sinks  deeper  down  into  the  pelvis.  Conse- 
quently the  upper  part  of  the  abdomen  becomes  less  prominent,  an 
Inclined  plane  takes  the  place  of  the  uppermost  bulging-  out,  and  the 
patient  breathes  more  freely  and  feels  relieved  of  an  uncomfortable 
pressure  in  the  upper  part  of  the  abdomen.  But  what  she  gains 
above  she  is  apt  to  lose  below.  The  pressure  of  the  head  against  the 
brim  or  the  walls  of  the  pelvis  interferes  with  the  free  circulation  of 
blood  in  the  lower  extremities  and  the  pelvis,  in  consequence  of  which 
the  veins  of  the  lower  extremities,  the  vulva,  and  the  rectum  swell 
and  become  varicose.  Serum  is  pressed  out  through  the  walls  of  the 
veins,  causing  increased  oedema  and  a  corresponding  feeling  of  un- 
wieldiness  and  impeded  facility  of  movement.  Many  women  suffer  a 
good  deal  from  backache  or  pains  shooting  down  the  thighs,  phenomena 
which  doubtless  are  due  to  pressure  on  the  nerve-trunks  which  take 
their  course  through  the  pelvis.  Finally  labor  sets  in.  The  pain  in 
the  back  becomes  stronger  and  shoots  forward  around  the  abdomen 
to  the  symphysis.  It  comes  with  intervals  of  about  ten  minutes  and 
lasts  about  one  minute.     The  woman  becomes  restless  and  wants  a 

11 


162  NORMAL   LABOR. 

pressure  on  her  lumbar  region,  be  it  by  leaning  herself  against  a  fixed 
object  or  by  having  another  woman  apply  her  hand  to  her  back. 
During  the  pain  the  uterus  may  be  seen  or  felt  to  be  harder  and  to 
rise  up  against  the  anterior  abdominal  wall.  The  intervals  between 
pains  become  gradually  shorter  and  the  pain  more  severe.  Often  the 
woman  vomits.  As  a  rule,  she  feels  hot  and  wants  fresh  air,  but  off 
and  on  she  may  shiver  and  have  a  sensation  of  cold.  There  is  a 
mucous  discharge  from  her  genitals,  which  later  becomes  mixed  with 
blood.  After  a  period  often  extending  over  many  hours,  there  is  a 
sudden  watery  discharge.  The  pain  becomes  more  severe  and  makes 
the  woman  groan  or  cry  out.  Instinctively  she  bends  forward  and 
contracts  her  abdominal  muscles  as  in  the  act  of  defecation,  and,  as  a 
rule,  an  evacuation  actually  takes  place  from  the  distended  anus.  She 
feels  the  need  of  taking  hold  with  her  hands  of  some  support  that  will 
help  her  in  steadying  her  body  and  making  her  efforts  more  effective  ; 
and  for  the  same  purpose  she  presses  her  feet  against  some  immovable 
object.  She  fdls  her  lungs,  holds  her  breath,  and  presses  downward 
and  backward  with  all  her  might,  while  her  face  is  flushed  and  often 
bathed  in  perspiration.  The  perineum  becomes  very  much  elongated. 
The  rima  pudendi  begins  to  gape.  The  head  appears  in  it  during  a 
pain,  but  recedes  during  the  following  interval,  thus  going  to  and  fro 
many  times,  until,  finally,  under  the  most  severe  pain,  it  is  pushed  out 
and  rises  in  front  of  the  vulva,  the  chin  riding  over  the  fourchette. 
Now  there  is  a  short  pause  in  which  the  bystander  may  notice  that 
the  head  rotates,  so  that  the  occiput,  instead  of  pointing  upward,  turns 
to  one  side.  Next  the  shoulders  appear  in  the  rima  pudendi,  in  the 
anteroposterior  line,  and  the  whole  body  of  the  child  is  pushed  out 
from  that  of  the  mother,  with  which  it  remains  connected  only  by  the 
umbilical  cord.  The  body  of  the  child  is  followed  by  a  gush  of  liquor 
amnii  and  blood. 

With  the  expulsion  of  the  child  all  pain  ceases  for  the  time  being, 
shortly  to  be  followed  by  a  new  attack,  but  of  a  type  infinitely  less, 
painful  than  that  which  accompanied  the  birth  of  the  child.  If  he 
would  see  the  end  of  the  drama  of  the  birth  of  a  human  being,  the 
bystander  might  have  to  wait  for  hours,  or  perhaps  till  the  following 
day,  when  the  placenta  is  expelled,  followed  by  the  membranes.  As, 
a  rule,  art,  therefore,  steps  in  and  ends  the  process  in  a  way  to  be 
described  hereafter. 


THE    EXPELLANT   FORCES.  163 

CHAPTER    V. 
THE    EXPELLANT   FORCES. 

We  shall  now  let  the  light  of  science  in  on  this  scene  and  begin  by 
a  consideration  of  the  expellant  forces  at  work  during  labor.  They  are 
five-fold  :  (1)  the  contraction  of  the  body  of  the  uterus  and  the  uterine 
ligaments^  (2)  the  contraction  of  the  diaphragm  and  the  abdominal 
muscles,  (3)  the  contraction  of  the  pelvic  and  perineal  muscles,  (4)  the 
elasticity  of  the  pelvic  floor,  and  (5)  gravity.  But  muscles,  again,  are 
made  to  contract  under  the  impulse  of  the  nervous  system,  and  it  is, 
therefore,  proper  to  ascertain  the  nature  and  seat  of  this  influence. 

§  1.  Innervation  of  the  Uterus. — Both  systems — the  cerebro- 
spinal and  the  sympathetic — are  concerned  in  labor.  It  is  mostly  an 
involuntary  act,  but  it  is  partially  under  the  control  of  the  will,  either 
in  furthering  or  in  restraining  it.  Anatomically  nerve-fibres  can  be 
followed  from  the  uterus  up  to  the  ganglia  of  the  solar  and  coeliac 
plexuses,  through  the  pelvic,  hypogastric,  and  aortic  plexuses.  On 
the  other  hand,  physiological  experiments  on  animals  have  shown  the 
presence  of  a  centre  for  uterine  contractions  in  the  medulla,  but  that 
the  connection  with  this  centre  is  not  indispensable  is  proved  by  the 
fact  that  bitches  in  which  the  spinal  cord  had  been  cut  and  women 
in  whom  the  conduction  had  been  interrupted  by  accidental  injuries 
have  been  observed  to  have  normal  labors.  What  is  necessary  is 
the  uninterrupted  connection  between  the  uterus  and  the  lumbar 
enlargement  of  the  spinal  cord  through  sympathetic  ganglia  situated 
between  the  second  and  third  lumbar  vertebrae. 

In  examining  the  causes  of  labor  we  have  seen  that  the  precise 
nature  of  the  stimulus  that  irritates  the  nervous  system  so  as  to  bring 
on  labor  is  not  known,  and  that  probably  several  elements  operate 
in  connection  with  one  another.  The  enormous  development  of  the 
cervical  ganglion  during  pregnancy  makes  it  likely  that  it  plays  a  chief 
role  in  this  respect.  Whatever  may  be  the  nature  of  the  irritant,  and 
Avherever  the  irritation  takes  place,  the  impulse  given  is  transmitted 
to  the  lumbar  part  of  the  spinal  marrow,  where  it  instigates  a  motory 
impulse  which  through  other  fibres  goes  back  to  the  uterus  and  causes 
its  muscle-bundles  to  contract. 

§  2.  Labor-pains. — Labor  is  the  only  physiological  function  which 
normally  is  accompanied  by  pain,  and  that  pain  often  of  the  most 
severe  kind.  This  feature  of  labor  has  impressed  itself  so  deeply  on 
the  human  mind  that  it  has  dominated  other  observations,  which, 
again,  has  led  to  the  unfortunate  confusion  of  two  intrinsically  dif- 
ferent phenomena — uterine  contractions  and  painful  sensations.  The 
poor  sufferer  is  much  surprised  to  hear  her  medical  assistant  and  de- 


164  NORMAL   LABOR. 

voted  friends  express  the  wish  that  she  may  have  "good  pains,"  the 
unsophisticated  mind  finding  it  difficult  to  combine  the  epithet  "good" 
with  a  condition  so  hateful  as  pain,  which  it  is  accustomed  to  look 
upon  as  an  unmitigated  evil.  Uterine  contraction  is  a  necessary  requi- 
site for  the  expulsion  of  the  foetus,  and  in  most  women  this  function 
is  accompanied  by  more  or  less  severe  pain.  In  this  respect  there 
obtains,  however,  the  greatest  individual  differences,  some  women 
suffering  the  tortures  of  the  rack,  while  others  have  hardly  any  real 
pain,  the  chief  difference  being  caused  by  the  relative  size  of  the  par- 
turient canal  and  the  foetus,  especially  the  head.  Paraplegic  women, 
in  whom  the  conduction  to  the  seat  of  perception  in  the  brain  is 
interrupted,  do  not  feel  any  pain  ;  and  the  same  is  the  case  with 
deeply  anaesthetized  women.  Most  women  left  to  themselves  experi- 
ence quite  considerable  pain,  which  increases  in  strength  as  labor 
progresses,  and  comes  on  with  shorter  and  shorter  intervals.  In  this 
respect  the  terminology  of  the  accoucheurs  of  former  days  is  of  inter- 
est. They  divided  labor-pains  into  proesagientes  (foreboding),  prcepa- 
rantes  (preparing, — i.e.,  dilating  the  os),  'propeUentes  (propellant, — i.e., 
pushing  the  foetus  through  the  parturient  canal),  and  conquassantes 
(shaking, — i.e.,  which  make  the  parturient  woman  tremble  all  over  her 
body).  The  moment  the  child  is  born  all  pain  ceases  for  a  while, 
and  the  poor  sufferer  feels  an  inexpressible  relief  and  in  most  cases 
no  less  delight  when  she  hears  the  baby  cry.  Physical  pain  is  at  an 
end,  the  woman  is  proud  of  having  accomplished  the  final  act  of  her 
destination,  and  maternal  love  gives  her  a  new  interest  in  life.  The 
pain  is  greatest  while  the  head  passes  the  vulva,  and  according  to 
some  authors,  especially  neurologists,  it  may  even  cause  unconscious- 
ness or  momentary  insanity,  but  such  cases  never  have  been  reported 
from  lying-in  hospitals. 

The  origin  of  the  pain  may  be  sought  in  compression  of  the  nerve 
ends  embedded  in  the  contracting  muscle,  in  pressure  on  nerve-trunks 
being  squeezed  between  the  bones  of  the  head  and  those  of  the  pelvis, 
and  in  expansion  of  the  lower  uterine  segment,  the  cervix,  the  vagina, 
and  the  vulva,  which  all  have  to  be  stretched  enormously  in  order  to 
allow  the  foetus  to  pass. 

The  pain  is,  as  a  rule,  first  felt  in  the  lumbar  region,  from  where 
it  later  encircles  the  abdomen  along  the  crest  of  the  ilium  and  the 
groins  down  to  the  symphysis  and  external  genitals,  following  the 
course  of  the  lumbar  nerves.  Sometimes  the  pain  also  shoots  down 
the  anterior  or  posterior  surface  of  the  leg,  in  the  track  of  the  crural 
or  the  sciatic  nerve,  and  causes  cramps  in  the  calves. 

If  the  question  is  asked  why  woman  should  suffer  so  much  in 
giving  birth  to  her  child,  the  writer  is  inclined  to  find  the  answer 
in  the  above-mentioned  disturbed  equilDjrium  between  the  size  of  the 


THE   EXPELLANT   FORCES.  165 

head  and  that  of  the  pelvis,  due  to  the  intehectual  evolution  of  man- 
kind, which  has  brought  about  an  increased  development  of  the  brain 
without  a  corresponding  increase  in  the  size  of  the  pelvis.  Another 
explanation  has  been  offered  to  the  effect  that  the  pain  is  present  in 
the  interest  of  the  child,  as  it  forces  the  mother  to  make  deep  inspira- 
tions and  thus  furthers  the  oxygenation  of  both  the  maternal  and  in- 
directly the  fetal  blood,  which  becomes  venous  by  the  obstruction  to 
free  circulation  caused  by  the  compression  the  foetus  suffers  during 
labor. 

The  pain  which  accompanies  the  loosening  and  expulsion  of  the 
placenta  is  situated  only  in  the  uterus  itself,  and  is  comparatively  in- 
significant and  of  short  duration,  the  parturient  canal  by  this  time  no 
longer  offering  any  resistance  to  so  small  and  soft  a  body  as  the  after- 
birth. 

In  animals  with  a  bicornute  uterus  the  contraction  can  be  seen  to 
be  distinctly  peristaltic,  beginning  at  the  outer  end  of  the  horns.  In 
the  human  female  such  a  disposition  may  perhaps  be  present,  but 
cannot  be  directly  observed.  What  we  do  see  and  feel  is  that  the 
contraction  comes  on  gradually,  reaches  an  acme,  where  it  lingers  for 
a  moment,  and  then  again  gradually  relaxes.  Tracings  with  the 
sphygmograph  show  that  the  relaxation  forms  a  longer  and  more 
slanting  line  than  the  contraction.  This  contraction  is  entirely  inde- 
pendent of  will-power  and  is  repeated  periodically,  at  first  with  inter- 
vals of  about  ten  minutes  and  later  of  only  two  or  three  minutes' 
duration,  the  whole  contraction,  acme,  and  relaxation  together  lasting 
about  a  minute.  When  the  head  is  born,  the  contractions  stop  for  a 
short  time,  and  after  the  expulsion  of  the  whole  foetus  there  is  a 
longer  interval.  After  the  loosening  and  expulsion  of  the  placenta 
from  the  uterus,  painful  uterine  contraction  ceases. 

The  contractions  are  strong  enough  to  numb  the  accoucheur's 
hand  if  during  one  of  them  it  is  in  the  interior  of  the  uterus,  and  to 
form  a  deep  indentation  on  the  parietal  bone  of  the  child's  head  if  it 
meets  with  unusual  resistance  at  the  promontory.  By  introducing 
a  rubber  bag  into  the  uterus  and  connecting  it  with  a  manometer,  it 
has  been  found  that  the  pressure  in  ordinary  cases  corresponds  to  a 
column  of  eighty  millimetres  of  quicksilver,  which  is  equal  to  a 
pressure  of  seventeen  pounds ;  but  if  there  is  an  unusual  resistance, 
the  force  may  amount  to  two  hundred  and  fifty  millimetres  of  quick- 
silver, or  fifty-five  pounds,  the  force  exercised  by  the  uterus  and  that 
by  the  abdominal  pressure  being  about  equal. 

We  have  seen  above  that  at  the  beginning  of  labor  the  uterus  is 
divided  into  a  much  larger  upper  portion  which  contracts,  the  walls 
becoming  hard  and  thick,  and  a  much  smaller  lower  part,  the  so-called 
lower  uterine  segment,  which  becomes  expanded  and  thinner,  and  to- 


166  NORMAL   LABOR. 

gether  with  the  cervix,  the  vagina,  and  the  vulva  forms  the  canal  through 
which  the  foetus  is  expehed  (Figs.  191,  192). 

When  labor-pains  begin,  the  uterus  becomes  longer  and  narrower, 
and  during  each  pain  it  is  seen  how  the  fundus  rises  against  the  an- 
terior abdominal  wall,  which  doubtless  is  due  chiefly  to  the  contrac- 
tion of  the  muscular  elements  of  the  round  ligaments,  which  increase 
so  much  in  size  during  pregnancy,  and  the  contraction  of  which 
presses  the  lower  part  of  the  uterus  against  the  pelvic  brim  in  the 
direction  of  its  axis.  The  broad  ligaments  are  of  minor  importance, 
but  contribute  to  the  maintenance  of  the  uterus  near  the  median  line 
of  the  body. 

Next  to  the  uterine  contractions  in  importance  as  an  expellant 
force  is  abdominal  pressure,  which  is  chiefly  exercised  by  the  contrac- 
tion of  the  diaphragm,  the  rectus,  pyramidalis,  obliquus  externus, 
obliquus  internus,  transversalis,  psoas,  and  iliacus  muscles,  but  impli- 
cates more  or  less  every  muscle  of  the  body,  as  the  laryngeal  muscles 
in  closing  the  glottis,  those  of  the  upper  extremities  in  seizing  fixed 
objects,  those  of  the  lower  extremities  in  pressing  the  feet  against  some 
suitable  support,  and  even  those  of  the  back  as  antagonists  to  the 
abdominal  muscles.  Of  the  above-named  muscles  the  diaphragm  is  the 
only  one  which  is  innervated  by  the  sympathetic ;  all  the  others  get 
their  nerve  supply  from  the  cerebrospinal  system,  and  are  consequently 
under  control  of  the  will ;  but  that  does  not  prevent  involuntary  re- 
flexes from  taking  place  in  them.  And  that  is  just  what  we  find  in 
labor.  Abdominal  pressure  is  brought  on  by  reflex  action  when  the 
ovum  is  ruptured  and  the  expulsion  of  the  foetus  begins,  but  the 
parturient  woman  has  the  power  at  will  to  increase  or  restrain  this 
pressure,  and  thereby  indirectly  even  to  make  the  uterine  contractions 
stronger  or  weaker.  This  goes  so  far  that  she,  within  certain  limits, 
can  postpone  the  actual  birth  of  the  child, — for  instance,  till  the  arrival 
of  persons  whom  she  wishes  to  be  present  at  her  delivery,  or  on 
whose  assistance  during  the  act  she  counts.  Emotions  have  also  the 
power  of  accelerating  or  retarding  labor.  While  it  progresses  favor- 
ably in  the  presence  of  trusted  friends,  it  may  become  arrested  by 
the  entrance  of  an  unsympathetic  individual. 

The  strong  levator  ani  muscle,  hugging  the  curvature  of  the  rectum 
from  behind  (Fig.  189)  and  even  sending  some  loops  into  the  septum 
between  the  rectum  and  the  vagina,  has  the  power  of  directing  the  foetus 
forward  towards  the  opening  of  the  parturient  canal ;  and  of  no  less 
importance  is  the  elastic  resistance  offered  to  the  progress  of  the  foetus 
in  the  direction  of  the  expellant  force  exercised  by  the  uterine  con- 
tractions and  the  abdominal  pressure.  The  pelvic  floor  with  its  mus- 
cles and  fasciae  becomes  highly  distended,  and  the  state  of  tension  in 
which  these  parts  are  becomes  itself  a  force  which  propels  the  foetus 


THE   EXPELLANT   FORCES. 


167 


in  the  opposite  direction.  The  small  perineal  muscles  are  too  weak 
and  too  overdistended  to  have  much  influence  on  labor. 

Gravity  is  of  minor  importance  except  when  the  woman  is  stand- 
ing up  or  takes  a  crouching  position  during  labor.  If  she  lies  on  her 
side  the  fundus  tips  over  so  as  to  be  below  the  exit  of  the  parturient 
canal,  and  then  the  weight  of  the  fcetus,  of  course,  works  in  opposi- 
tion to  the  expellant  forces,  a  condition  which  the  accoucheur,  as  we 
later  shall  see,  may  turn  to  profit. 

§  3.  Stages  of  Labor. — For  convenience  labor  is  divided  mto 
three  stages, — the  opening  of  the  uterus,  the  expulsion  of  the  child, 
and  the  expulsion  of  the  ovum. 

The  First  Stage,  or  the  Stage  of  Dilatation. — The  effect  of  the 
contraction  of  the  greater  part  of  the  hollow  muscle  formed  by  the 
uterus  differs  somewhat  in  primiparae  and  pluriparse.     In  the  former 

Fig.  201. 


Fig.  202. 


Fig.  203. 


Diagram  of  the  dilatation  of  the  cervix  in  a  pluripara.    (Sehroeder.)    o.i.,  internal  os ;  o.e.,  exernal 
OS ;  C.R.,  contraction  ring.    In  primiparse  the  first  stage  occurs  during  pregnancy. 

the  lower  uterine  segment  and  the  upper  part  of  the  cervix  had  be- 
come expanded  towards  the  end  of  pregnancy,  and  need,  •therefore, 
not  be  so  after  the  commencement  of  labor.  The  forces  which  are  at 
work  to  produce  this  condition  are  by  French  obstetricians  aptly  dis- 
tinguished as  ^'■travail  insensible'''  (Fig.  163).  In  pluriparae  this  work 
is  accomplished  by  the  labor-pains,  of  which  the  patient  is  conscious 
(Figs.  201,  202,  203).  In  both  classes  dilatation  continues  from  above 
downward  till  the  cervix  is  all  taken  up  in  the  cavity  of  the  body, 
which  is  technically  called  the  obliteration  of  the  cervix,  and  the  os 
externum  is  fully  dilated,  at  which  time  it  measures  4|  inches  in 
diameter.  During  this  process  the  lower  uterine  segment  and  the 
cervix  become  so  elongated  that  finally  they  measure  4  inches  in 


168 


NORMAL   LABOR. 


length.  The  contraction  ring,  on  the  contrar}',  moves  upward,  so 
that  the  expelHng  part  of  the  uterus  becomes  shorter,  wliile  the  passive 
part  becomes  longer  and  wider.  The  contraction  pressing  on  the 
o^Tim  and  all  its  contents,  a  part  of  the  licjuor  amnii  is  pressed  beyond 
the  head,  accumulating  between  it  and  the  lower  pole  of  the  ovum 

Fig.  204. 


stomach 


, — Duodenum 


Contraction 


External  os 


Rectum 


Sagittal  section  through  the  body  of  a  quadnpara     Opening  stage      (Olshausen-Veit.)    The  cervix 
is  little  dilated.    Behind  the  symphysis  and  the  bladder  appears  the  lower  uterine  segment. 


(Fig.  204).  During  a  contraction  this  bag  becomes  tense,  and  during 
relaxation  it  hangs  down  in  a  limp  condition. 

If  the  head  is  tightly  surrounded  by  the  uterus,  as  usual  in  primi- 
parae,  these  ^'^ first  waters''''  may  be  absent,  and  the  membranes  are  then 
in  close  contact  with  the  skull.  When  there  is  such  a  bag  of  waters 
in  front  of  the  head,  it  is  an  advantage,  since  during  the  uterine  con- 
tractions it  becomes  tense  and  serves  as  a  softer  dilator  for  the  cervix 
and  OS  than  do  the  hard  bones  of  the  skull. 

When  the  os  is  fully  dilated,  "  the  waters  break,''' — that  is,  the  ovum 


THE    EXPELLAXT    FORCES. 


169 


is  ruptured,  and  that  part  of  the  liquor  amnii  that  was  situated  be- 
tween the  lower  end  of  the  ovum  and  the  head  escapes,  mostly  mixed 


Fig.  205. 


Sagittal  section  through  the  frozen  body  of  a  woman  who  died  during  the  stage  of  expulsion  of 
the  fcetus.  (Braune.)  A,  pancreas;  B,  stomach;  C,  os  uteri  internum;  Z),  bladder;  Ji,  os  uteri 
externum;  /',  urethra;  G,  ca-liac  artery;  II,  superior  mesenteric  artery;  I,  vena  portfe;  J,  left 
renal  vein;  A",  abdominal  aorta;  i,  duodenum;  J/,  placenta;  X,  left  iliac  vein;  0,  os  uteri  inter- 
num ;  P,  rectum  ;  Q,  os  uteri  externum  ;  li,  rectum  ;  S,  liquor  amnii. 

with  a  little  blood.     But  generally   this  rupture  occurs  while  there 
is  still  left  a  finger-breadth  of  cervix,  especially  in  front,  and  when 


170  NORMAL   LABOR. 

the  OS  is  only  three  inches  in  diameter.  In  other  cases  the  ^'■hag  of 
ivcders'''  remains  unruptured  during  a  large  part  of  the  second  stage,  the 
stage  of  expulsion  (Fig.  205),  and  the  whole  unruptured  ovum  may  be 
expelled  with  the  child  in  it.  In  other  cases  again  that  portion  of  the 
ovum  which  surrounds  the  head  of  the  foetus  is  torn  off  and  encom- 
passes it  when  the  child  is  born.  This  piece  of  membrane  is  called 
a  caul^  and  was  supposed  to  betoken  great  prosperity  for  the  person 
born  with  it  and  to  be  an  infallible  preservative  against  drowning,  as 
well  as  to  impart  tlie  gift  of  eloquence.  During  the  eighteenth  cen- 
tury seamen  often  gave  from  fifty  to  one  hundred  and  fifty  dollars  for 
a  caul  (Century  Dictionary). 

Sometimes  there  is  a  discharge  of  a  watery  fluid  from  the  uterus, 
and  still  a  bag  forms.  This  may  be  due  to  an  accumulation  of  a 
serous  fluid  between  the  uterus  and  the  ovum — "  external  waters,''^  or 
oftener  to  the  occurrence  of  the  rupture  not  at  the  lower  pole  of  the 
ovum,  but  at  a  higher  level. 

When  the  internal  os  begins  to  dilate,  the  ovum  must  separate 
from  the  uterine  wall,  and  when  the  external  os  becomes  stretched, 
small  tears  take  place  in  its  edge,  both  of  which  occurrences  give  rise 
to  a  little  bleeding,  and  explain  the  bloody  character  of  the  discharge 
during  the  stage  of  dilatation. 

In  primiparse  the  os  becomes  so  distended  that  it  is  felt  as  a  tense 
sharp  edge,  while  in  pluriparse  the  rim  remains  thicker.  If  the  ovum 
is  ruptured  prematurely,  the  external  os  may  again  collapse  and 
become  smaller  than  it  Avas  before. 

The  bladder  is  gradually  drawn  up  over  the  symphysis  pubis  and 
stripped  of  its  peritoneal  covering,  as  seen  in  Fig.  205. 

The  contraction  of  the  uterus  and  pressure  against  the  brim  of 
the  pelvis  drive  the  blood  and  lymph  into  the  walls  of  the  vagina  and 
vulva,  causing  hypergemia  and  serous  infiltration  which  still  further 
increase  the  softening  of  these  parts  begun  during  pregnancy.  That 
the  large  uterine  sinuses  are  emptied  by  the  contraction  of  the  mus- 
cular wall  can  be  seen  by  comparing  Braune's  plate  C,  reproduced  in 
Fig.  205,  with  his  plate  B,  reproduced  in  Fig.  139.  The  glands  are 
stimulated  to  increased  action,  lubricating  the  canal  through  which  the 
foetus  has  to  pass. 

The  Second  Stage,  or  the  Stage  of  Expulsion  of  the  Fcetus. — 
When  the  external  os  is  fully  dilated,  the  second  stage,  that  of  expul- 
sion, theoretically  begins ;  but  nature  is  not  bound  by  our  artificial 
divisions,  and  often  the  head  has  descended  considerably  into  the  pel- 
vic cavity  before  the  os  is  completely  dilated,  and  in  primiparpe  it  is 
the  rule  that  it  does  so  even  during  the  last  months  of  pregnancy. 

When  the  waters  have  broken,  there  follows  generally  a  short 
interval  during  which  the  labor-pains  cease,  but  only  to  be  renewed 


THE  EXPELLANT  FORCES. 


171 


Fig.  206. 


Head  pressing  on  perineum.     (Chiari.) 


172  • 


NORMAL   LABOR. 


soon  after  with  increased  force.  They  now  follow  more  rapidly  upon 
one  another,  are  more  painful,  and  elicit  deeper  groans  from  the  suf- 
ferer. While  in  the  stage  of  dilatation  she  chatted  cheerfully  with  her 
nurse  and  friends  during  the  intervals  of  pain,  her  whole  attention 
now  becomes  concentrated  on  her  sufferings. 

Gradually  the  external  os  is  drawn  higher  up,  until  it  is  beyond 
reach  of  the  examining  fmger.  The  contraction  ring  also  moves  higher 
up,  and  consequently  the  uterine  force  is  diminished,  which  can  be 
directly  proved  by  inserting  a  rubber  ball  into  the  rectum  of  the  foetus 
in  cases  of  breech  presentation  and  connecting  it  with  a  monometer. 
A  new  force,  that  of  abdominal  pressure,  supplements  or  replaces  the 
uterine  contractions.  As  stated  above,  this  is  at  first  called  into  action 
by  a  reflex  from  the  perineum,  but  is  under  control  of  the  cerebro- 
spinal nervous  system,  so  that  the  patient  at  will  can  bear  down  or 
hold  back  the  pressure.  The  perineum  becomes  enormously  dis- 
tended (Fig.  206),  carrying  the  rima  pudendi  forward  and  upward. 
If  the  rectum  has  not  been  evacuated  shortly  before  by  means  of  an 
enema,  fecal  matter  is  pressed  out  through  the  expanded  anus,  which 


Fig.  207. 


Flexion  of  head  during  second  stage.  (Pinard  and  Varnier.)  The  shaded  head  shows  the 
minor  flexion  found  in  pluriparse  and  the  unshaded  the  stronger  flexion  observed  in  primiparse. 
oc,  od,  occiput. 

forms  a  large  open  ring  an  inch  or  more  in  diameter.  Sometimes 
there  is  also  an  evacuation  from  the  bladder.  By  separating  the  labia 
majora,  we  may  see  the  head  in  the  vaginal  entrance.  During  each 
pain  it  is  pushed  lower  down,  and  in  each  interval  between  pains  it 
recedes  again.  Next,  the  vulva  begins  to  gape  in  a  similar  way,  and, 
finally,  the  head  rolls  out  with  the  occiput  in  front  of  the  symphysis 
pubis  and  the  face  passing  over  the  fourchette. 

Then  there  is  a  short  pause,  but  soon  labor-pains  begin  again,  the 
shoulders  take  the  place  occupied  by  the  head,  and  the  whole  body 


THE   EXPELLANT   FORCES. 


173 


of  the  foetus,  which  now  is  called  the  child,  is  expelled.  The  hips 
being  retained  a  little,  the  obstetrician,  as  a  rule,  interferes  and  pulls 
out  the  lower  half  of  the  body. 

The  Ilechanism  of  Labor. — The  passage  of  the  head  of  the  fcetus 
through  the  pelvic  cavity  is  a  mechanical  problem  governed  by  the 

Fig.  208. 


Internal  rotation  and  extension.    (Tarnier  and  Chantreuil,  1.  c.) 


fundamental  law  that  a  body  moves  in  the  direction  where  there  is 
least  resistance.  If  the  head  at  the  time  labor  begins  is  above  the 
brim  of  the  pelvis,  it  will  enter  the  transverse  diameter  of  the  same 
with  its  occipitofrontal  diameter.  The  sagittal  suture  is  felt  running 
parallel  to  the  promontory  but  nearer  to  it  than  to  the  symphysis — 
the  ''obliquity  of  Naegele,'" — which  is  due  to  gravity  acting  on  the 
uterus,  a  lesser  degree  of  resistance  being  offered  by  the  yielding 
anterior  abdominal  wall  than  by  the  vertebral  column  behind.  Only 
in  wide  pelves  the  head  enters  in  the  oblique  diameter. 


374 


NORMAL   LABOR. 

Fig.  209. 


Fig.  210. 


Fig.  211. 


Extension  of  head  and  opening  of  the  rima  pudendi.     (Varnier.) 


THE    EXPELLANT    FORCES. 


175 


The  head  forming  a  lever,  one  branch  of  which — the  distance 
from  the  occipito-atlantal  articulation  to  the  most  prominent  point  of 
the  occiput — is  much  shorter  than  the  other — the  distance  between 
the  articulation  and  the  most  prominent  part  of  the  forehead, — the 
descent  is  combined  with  a  flexion  (Fig.  207). 

As  the  head  descends  more,  the  occiput  turns  forward — internal 
rotation  (Fig.  208),  the  cause  of  which  is  much  debated.     In  the  writer's 

Fig.  212. 


External  rotation. 

opinion  it  is  due  to  the  strong  resistance  offered  by  the  spine  of  tlie 
ischium  and  the  sacrosciatic  ligaments,  while  in  front  and  below  there 
are  the  hollow  smooth  surface  of  the  ilium  and  the  ischium,  the  some- 
what yielding  obturator  membrane,  and  finally  the  free  outlet  presented 
by  the  pubic  arch.  Thus  following  the  line  of  least  resistance  the 
head  almost  or  entirely  reaches  with  its  long  axis  the  median  line. 
Since  now  all  resistance  ceases  in  front  and  pressure  continues  from 
behind,  and  the  posterior  branch  of  the  lever  constituted  by  the  head 
is  shorter  than  the  anterior,  the  occiput  rises  outside  the  maternal 
body  in  the  direction  of  the  fetal  back, — extension  (Figs.  208-211). 

When  the  head  is  in  or  near  the  anteroposterior  diameter  of  the 
outlet,  the  shoulders  are  in  or  near  the  transverse  diameter  of  the 


176  NORMAL   LABOR. 

pelvic  cavity,  and  the  same  forces  and  resistance  acting  on  them  as 
•formerly  on  the  head,  the  one  that  is  placed  most  forward  is  pushed 
downward  and  forward  in  a  curved  line,  until  it  passes  under  the 
pubic  arch,  the  result  of  which  necessarily  is  that  the  occiput  turns 
in  the  direction  which  it  occupied  while  passing  through  the  pehic 
canal, — external  rotation  (Fig.  212).  In  other  words,  in  the  left  oc- 
cipito-anterior  position  the  small  fontanelle  describes  part  of  a  circle 
in  the  direction  of  the  left  thigh  of  the  mother,  while  the  right 
shoulder  of  the  foetus  is  turned  forward.  Exceptionally  the  left 
shoulder  is  ahead  of  the  right  in  this  position,  and  then  the  occiput 
turns  in  the  opposite  direction,  passing  the  median  line  and  moving 
towards  the  mother's  right  thigh. 

As  a  rule,  the  anterior  shoulder  is  born  first,  but  exceptionally  it 
is  the  posterior  that  passes  the  rima  pudendi  before  the  other. 

The  resistance  offered  by  the  lower  lumbar  vertebrae,  as  well  as 
the  contraction  ring,  prevents  the  flexed  body  from  following  the  head 
in  its  descent,  and  consequently  the  body  becomes  stretched  out. 

The  Third  Stage,  or  the  Stage  of  Expulsion  of  the  After-Birth. 

^^Vhen  the  child  is  born,  uterine  contraction  and  pain  cease  for  a 

while,  but  after  a  pause  lasting  from  five  to  twenty  minutes  or  longer, 
new^  but  much  less  painful  contractions  follow.  By  the  diminution  of 
the  area  on  which  it  adheres  to  the  womb,  the  placenta  is  thrown  off, 
and,  according  to  Matthews  Duncan,  rolled  together,  with  the  fetal 
side  turned  inward,  and  expelled  edgewise,  without  the  accumulation 
of  any  blood  between  it  and  the  placental  site  (Fig.  213).  This  is 
the  way  in  which  the  placenta  is  detached  if  left  alone,  but  if  the 
cord  is  pulled  on,  as  used  to  be  the  mode  of  delivery,  a  heematoma 
is  formed  between  the  placenta  inverted  in  cup  form  and  the  placental 
site  (Fig.  214).  This  was  looked  upon  as  normal  by  Baudelocque, 
and  is  so  by  several  modern  authors,  and  it  may  exceptionally  be 
found  even  when  no  traction  has  been  exercised  on  the  cord. 

By  ■  uterine  contraction  the  placenta  is  expelled  into  the  vagina 
and  puhs  on  the  membranes,  inverting  them  and  detaching  them  from 
above  downward.  It  has  been  asserted  that  a  peculiar  crunching 
sound  is  produced  by  the  detachment  of  the  placenta.  The  writer 
has  always  looked  upon  the  third  stage  of  labor  as  fraught  with  so 
much  danger  for  the  patient  that  he  has  not  felt  justified  in  watching 
the  natural  process  of  the  detachment  and  expulsion  of  the  after- 
birth, but  interferes  as  will  be  described  later.  What  he  can  state 
from  his  personal  experience  in  Csesarean  section  is  that  he  did  not 
hear  any  sound  produced  by  the  spontaneous  loosening  of  the  placenta, 
but  that  a  sound  much  like  that  heard  on  pressing  a  snowball  is  heard 
in  detachmg  the  membranes  from  the  inside  of  the  uterus.  He  uses 
Crede's  expression  method,  and  his  experience  is  that  the  placenta  is 


THE    EXPELLAXT    FORCES. 


177 


pushed  outside  of  the  genitals  edgeways,  followed  by  the  inverted 
membranes  forming  a  bag  containing  from  half  a  pint  to  a  pint  of 
blood.  When  this  sac  is  reinverted  over  the  umbilical  cord,  some 
blood-clots  are  found  adherent  to  the  maternal  surface  of  the  placenta. 
That  the  loss  of  blood  is  so  moderate  is  due  to  the  compression  and 
contraction  of  the  blood-vessels  severed  by  the  detachment  of  the 


Fig.  21.3. 


Fig.  214. 


Expulsion  of  the  placenta  according  to  Duncan. 
(Charpentier.) 


Expulsion  of  the  placenta 
according  to  Baudelocque. 
(Pinard.)  oe,  external  os  ;  cc, 
contraction  ring ;  PL,  placenta 
folded  together  over  the  ma- 
ternal surface  ;  h,  hsematoma  ; 
ves.,  bladder;  m,  membranes. 


placenta  and  the  membranes  from  the  inside  of  the  uterus.  In  nature 
the  placenta  would  probably  only  be  expelled  from  the  uterus  into 
the  vagina,  whence  it  would  fall  out  by  its  own  weight,  dragging  the 
membranes  after  it,  when  the  woman  rose  to  her  feet. 

Immediately  after  the  expulsion  of  the  placenta  from  the  uterus 
this  forms  a  hard  ball  above  the  symphysis,  but  soon  the  strong  con- 
traction relaxes  and  the  fundus  mounts  during  several  days  to  about 
an  inch  under  the  umbilicus  or  even  higher. 

§  4,  Influence  of  Labor  on  the  Mother. — During  each  pain  the 
frequency  of  the  pulse  increases  in  the  same  ratio  as  the  contraction, 
and  decreases  again  during  relaxation. 

The  patient's  temperature  rises  a  little  in  the  course  of  lalDor. 
Respiration  is  interrupted  during  the  bearing  down,  and  becomes 
more  rapid  during  the  intervals  between  pains.     The  face  is  flushed 

12 


178 


NORMAL   LABOR. 


during  labor,  but  after  the  expulsion  of  the  child  the  congestion  to 
the  head  ceases,  and  the  sudden  ansemia  of  the  brain  may  cause 
faintness,  vomiting,  or  perhaps  even  unconsciousness.  Quite  fre- 
quently the  mother  feels  exhausted  and  cold,  and  she  may  even  have 
a  chill,  which  is  no  sign  of  any  abnormal  condition. 

§  5.  Influence  of  Labor  on  the  Child. — After  the  bag  of  waters 
has  broken,  the  effect  of  the  strong  uterine  contractions  is  to  pack 

the  different  parts  of  the  child  tightly  to- 
gether, which  especially  exercises  great  in- 
fluence on  the  head,  modifying  its  form,  the 
so-called  moulding.  The  sagittal  suture  being 
nearer  to  the  promontory  than  to  the  sym- 
physis, pressure  bears  more  strongly  on  the 
anterior  parietal  bone,  which  becomes  more 
convex,  while  the  posterior  becomes  more 
flattened  (Fig.  215).  The  edges  of  the  bones 
composing  the  skull  are  made  to  overlap  one 
another,  the  anterior  parietal  bone  being 
pushed  in  under  the  posterior,  the  occipital 
and  the  frontal  in  under  both. 
While  the  external  os  is  dilating,  there  is  less  pressure  on  that 
part  of  the  fetal  head  that  occupies  the  centre  than  in  the  circumfer- 
ence, in  consequence  of  which  serum  is  pressed  out  at  the  presenting 

Fig.  216. 


Asymmetry  of  head  of  child 
born  in  right  oceipito-anterior 
position.    (Olshausen-Veit.) 


--■ External  OS 


Formation  of  caput  succedaneum.     (Olshausen-Veit.)    X>  centre  of  swelling. 

point.  It  may  even  contain  some  blood,  owing  to  capillary  ruptures, 
and  forms  a  swelling  called  caput  succedaneum^  which  is  situated  on 
the  anterior  bregmatic  bone  and  the  adjacent  part  of  the  occipital 
bone  (Fig.  216).     The  slower  the  dilatation  is  the  more  this  serous 


CAUSE    OF   RESPIRATION.  I79 

infiltration  will  take  place.  As  a  rule,  it  is,  therefore,  more  marked 
in  primipara;  than  in  multiparse.  A  second  such  swelling  may  form 
on  a  separate  spot  corresponding  to  a  free  central  portion,  while  the 
surrounding  parts  are  compressed  in  opening  the  rima  pudendi. 
These  swellings  and  distortions  disappear  spontaneously  in  the  course 
of  a  few  days  after  the  birth  of  the  child. 

The  fetal  heart-beat  becomes  slower  during  a  labor-pain  and  faster 
during  the  interval,  but  towards  the  end  of  labor  the  retardation 
becomes  permanent,  even  during  the  interval,  a  phenomenon  that 
probably  is  due  to  the  increasing  venosity  of  the  blood  caused  by  the 
impeded  circulation. 

The  movements  of  the  child  are  also  much  weakened  and  are 
hardly  felt  at  all  during  labor,  especially  after  the  rupture  of  the 
ovum,  when  the  foetus  becomes  subjected  to  such  a  pressure  and 
fixation  that  it  hardly  can  move. 

§  6.  Duration  of  Labor. — Labor  lasts  much  longer  in  primiparae, 
in  whom  the  narrower  soft  parts  offer  greater  resistance,  than  in 
pluriparae.  In  the  former  it  lasts  on  an  average  twenty  hours,  in  the 
latter  twelve,  the  difference  being  most  marked  in  the  length  of  the 
first  stage.  There  are,  however,  the  greatest  individual  differences, 
some  multiparous  women  getting  through  in  a  single  hour,  while  in 
some  other  cases,  especially  if  the  waters  break  early,  the  process 
may  last  for  days. 

The  second  stage  takes  on  an  average  an  hour  and  three-quarters 
in  primiparEe  and  only  one  hour  in  ijluriparse. 

The  third  stage  varies  very  much  in  length.  In  the  vast  majority 
of  cases  it  takes  hours,  and  may  occasionally  take  over  twenty-four 
hours,  as  observed  in  institutions  in  which  this  stage  is  left  to  nature. 


CHAPTER    VI. 

CAUSE    OF   EESPIRATION. 

In  the  uterus  the  child  under  normal  circumstances  is  in  a  condi- 
tion called  apnoea.  The  blood  being  oxidized  in  the  placenta,  it  con- 
tains oxygen  enough  for  all  purposes,  and  there  is  no  stimulus  that 
impels  the  foetus  to  respire.  Almost  immediately  after  its  birth,  the 
child  fills  its  lungs  with  au*  and  cries,  as  if  it  were  in  pain,  and  if 
the  shoulders  are  arrested,  we  may  even  see  the  purple-colored 
head  make  fruitless  attempts  at  breathing.  Much  ingenuity  has  been 
bestowed  upon  the  question.  What  makes  the  child  respire  ?  Some 
cynic  has  said  that  the  child  cries  because  it  is  sorry  to  enter  this 
miserable  world.  The  chief  cause  is  doubtless  to  be  sought  in  a 
change  in  the  blood  by  which  the  amount  of  oxygen  circulating  in  it 


180  NORMAL   LABOR. 

is  diminished.  If  tlie  placenta  is  detached,  the  source  of  oxygen  is 
cut  off  altogether,  but  respiration  often  begins  while  the  placenta  is  not 
only  in  the  uterus,  but  even  when  it  to  all  appearances  is  not  detached. 
Perhaps  the  contractions  of  the  uterus  deprive  it  of  a  large  part  of 
its  blood,  as  when  by  manual  pressure  we  expel  the  water  from  a 
sponge.  The  purple,  almost  blue,  color  of  the  face  of  the  child 
arrested  in  front  of  the  parturient  canal,  bears  witness  to  a  strong 
passive  congestion  to  the  head,  Avhich  may  stimulate  the  centre  of 
respiration  to  activity.  The  impression  of  the  comparatively  cold  air 
meeting  the  child  in  the  outer  world  does  not  seem  to  be  of  marked 
importance,  since  children  begin  to  breathe  even  if  experimentally 
they  are  born  into  water  of  the  temperature  of  the  body.  That  the 
low  temperature  of  the  ambient  medium  and  other  irritants  have,  how- 
ever, some  influence  appears  clearly  by  the  effect  of  measures  used  to 
induce  respiration  in  asphyctic  children.  One  of  these  is  to  plunge 
the  child  alternately  into  hot  and  ice-cold  water,  and  the  writer  has 
invariably  noticed  that  the  first  cry  is  uttered  while  the  child  is  in  the 
cold  water.  When  first  the  centre  of  respiration  in  the  medulla  is 
stimulated  to  action,  the  impulse  goes  out  through  the  pneumogastric 
nerve  to  the  lungs  and  through  other  cerebral  and  spinal  nerves  to  all 
the  muscles  concerned  in  inspiration  and  expiration. 


CHAPTER    VII. 

CONDUCT    OF   NORMAL   LABOR. 

When  engaged  to  attend  a  woman  in  her  confinement,  it  is  proper 
for  the  obstetrician  to  make  external  and  internal  examinations,  as 
described  above  (pp.  107-120),  to  give  advice  in  regard  to  dress  and 
regimen  during  pregnancy  (pp.  126-128),  if  necessary  to  prescribe  for 
constipation  or  anaemia,  direct  the  patient  to  send  her  urine  for  exam- 
ination once  a  month,  and  to  report  to  him  as  soon  as  she  notices 
anything  abnormal  in  her  functions. 

Materials  Needed. — Al30ut  two  weeks  before  the  expected  day  of 
confinement  the  writer  orders  the  following  objects  to  be  provided 
for  the  occasion : 

Lysol,    "giv  ; 

Alcohol,   ,^  viii ; 

Thick  gutta-perch  tissue,  1  yard  ; 

Chloroform,    ^ii  ; 

Fluid  extract  of  ergot,   f  i  ; 

Absorbent  cotton,  1  pound  ; 

Whiskey  or  brandy  ; 

Unbleached  muslin,  one  yard  wide,  6  yards  ; 

Safety-pins,  1  dozen  large  and  1  dozen  small ; 


CONDUCT   OF   NORMAL   LABOR. 


181 


Fig.  217. 


A  douche-pan  (Fig.  217)  ; 

A  fountain  syringe  (Fig.  218)  ; 

A  rubber  sheet  3  by  IJ  yards  ; 

A  piece  of  the  same  material  IJ  by  1  yard  (where  economy  is  an  object,  so- 
called  white  enamel,  a  kind  of  thin  oil-cloth  used  for  table-covers  and  inexpensive, 
may  be  substituted  for  both)  ; 

6  small  unbleached  muslin  quilts,  about  a  yard  square,  found  in  the  dry- 
goods  stores,  or  a  similar  clean  absorbent  material  (the  quilts  should  be  washed 
before  using  them)  ; 

A  baby  bath-tub  ; 

A  large  dish-pan  ; 

3  basins  ; 

3  pitchers  ; 

Ice  ; 

Hot  and  cold  water. 

In  country  practice  and  in  city  practice  among  the  poor  the  phy- 
sician must  carry  everything  with  him  and  often  has  to  put  up  with 
less  numerous  utensils  and  materials,  but  he  should  at  least  insist  on 
some  clean  sheets,  a  large  dish-pan,  and  hot  and  cold  water.  For  that 
kind  of  practice  some  physicians 
carry  m  their  satchel  an  inflatable 
rubber  cushion  with  apron  (Fig. 
219).  If  desired,  this  can,  however, 
easily  be  improvised  by  merely  car- 
rying a  piece  of  sheet-rubber,  one 
end  of  which  is  drawn  around  a 
sheet  rolled  together  like  a  sausage, 
and  bent  so  as  to  form  the  three 
sides  of  a  square  or  three-fourths 
of  a  circle. 

Assistants. — The  doctor  should 
also  secure  proper  assistance.  If 
the  patient  can  afford  it,  a  trained 
nurse  who  has  had  a  full  course  in 
a  lying-in  hospital  is  a  great  comfort 
to  her  and  an  invaluable  help  to 
the  physician.  Sometimes  we  have, 
however,  to  be  satisfied  with  one  of 
those  cheap  so-called  nurses  who, 
without  having  learned  anything,  make  a  living  by  attending  to  sick 
persons  and  lying-in  women ;  and  often  there  is  no  nurse  at  all. 
Under  such  circumstances  it  is  particularly  important  to  inform  the 
patient  that  frequently  the  help  of  three  persons  besides  the  ac- 
coucheur may  be  needed.  One  of  them  should  be  the  husband,  if 
there  is  one.  I  have  always  found  that  nobody  has  so  soothing  and 
comforting  an  influence  on  the  parturient  woman  as  the  author  of 


Douche-pan. 


182 


NORMAL   LABOR. 


her  trouble,  and  it  is  certainly  the  least  he  can  do  for  her  to  witness 
her  sufferings.  Woe  to  those  thin-blooded,  pale-faced,  selfish  men 
who  declare  they  cannot  see  blood,  and  who  keep  away  from  home 

or  retire  to  another  room  in 
Fig.  218.  order  not  to  hear  the   cries 

of  their  wives  in  labor.  They 
are  unworthy  of  a  woman's 
love  and  unfit  for  the  stern 
duties  of  fatherhood.  The 
second  person  may  be  the 
patient's  mother,  if  she  is  not 
too  old,  too  nervous,  or  too 
sentimental.  She  is  a  living 
proof  to  the  sufferer  that  one 
may  go  through  such  an 
ordeal  and  still  be  alive.  The 
third  should  be  some  kind- 
hearted  friend.  But  these 
persons  should  only  come 
when  needed,  and  all  others  should  be  kept  away.  They  only  make 
trouble,  consume  the  oxygen  of  the  air  in  the  room,  and  often  make 

Fig.  219. 


Fountain  syringe. 


Inflatable  rubber  cushion  with  apron. 


the  patient  nervous  by  their  exaggerated  sympathy  or,  still  worse,  by 
relating  all  they  have  gone  through  themselves  or  witnessed  in  others 


CONDUCT   OF   NORMAL   LABOR. 


183 


on  similar  occasions.  Ordinarily  the  doctor  has  more  real  assistance 
from  an  experienced  nurse  than  from  the  three  other  persons  to- 
gether. 

Choice  of  Room. — If  we  have  the  choice,  we  should  choose  a  large, 
w^ell-ventilated  room  with  a  good  light,  a  cool  one  in  summer-time 

Fig.  220. 


Bulb  and  valve  syringe. 


and  a  warm  one  in  winter,  preferably  with  morning  sun.  We  must 
also  be  guided  somewhat  in  our  choice  by  the  disposition  of  gas- 
l)rackets  or  electric  lamps.  Most  confinements  take  place  at  night, 
and  a  good  light  not  only  is  a  comfort,  but  also  may  be  an  important 
factor  in  case  of  complications  calling  for  special  interference.  In  the 
hut  of  the  poor  there  may  be  only  a  tallow  candle  or  a  kerosene- 
oil  lamp  ;  but  the  doctor  should, 

whenever  possilDle,  secure  suffi-  Fig.  221. 

cient  illumination  for  the  proper 
performance  of  his  work. 

Whenever  a  physician  is 
called  to  a  pregnant  woman,  he 
should  repair  immediately  to 
her  residence.  As  a  rule,  espe- 
cially in  the  case  of  a  primipara, 
he  will  be  called  long  before  his 

services  are  needed,  but  it  is  his  duty  to  satisfy  himself  at  once  about 
her  condition.  If  he  finds  that  labor  has  not  begun  or  is  just  com- 
mencing, he  may  leave  his  patient  and  attend  to  other  work.  It  is 
the  writer's  practice  to  come  again  about  every  two  hours  and  to 
stay  when  the  os  is  dilated  to  the  size  of  a  fifty-cent  piece. 


Esmarch's  chloroform-mask. 


184  NORMAL   LABOR. 

The  Obstetrical  Bag. — I  shall  now  frankly  tell  what  I,  who  am 
called  chiefly  in  consultation  when  some  difficulty  arises,  and  when  I 
am  expected  in  most  cases  to  perform  an  operation,  carry  in  my 
satchel. 

First  a  few  words  about  the  bag  itself.  It  is  an  alligator  satchel, 
sixteen  inches  long,  eight  inches  high,  and  ten  inches  wide  when  open. 
In  one  side  is  a  pocket  running  the  full  length  of  the  bag;  on  the 
other  I  have  had  a  movable  leather  strip  put  into  cuts  in  the  leather 
lining,  one  and  one-half  inches  apart.  Thus  a  row  of  eight  compart- 
ments is  formed  for  bottles,  most  of  them  containing  one  fluidounce, 
but  that  with  chloroform  having  the  capacity  of  two  ounces. 

In  this  satchel  I  carry  : 

A  stethoscope  ; 

A  Davidson's  bulb  and  valve  syringe  (Fig.  220)  ; 

A  hypodermic  syringe,  with  tablets  of  morphine  and  atropine  and  bottles  con- 
taining tincture  of  digitalis,  spiritus  glonoini,  and  a  solution  of  sulphate  of 
strychnine  ; 

Garrigues's  intra-uterine  tube,  with  rubber  tubing  for  establishing  connection 
between  the  tube  and  the  syringe  ; 

A  nail-brush  ; 

A  pelvimeter  ; 

A  tape-measure  ; 

A  set  of  Barnes's  cervical  dilators,  with  metal  attachment  fitting  the  syringe 
and  having  a  stopcock  ; 

A  colpeurynter ; 

Arthur  Muller's  modification  of  Champetier  de  Ribes's  metreurynter; 

Arthur  Muller's  cervical  dilator  ; 

A  ball  of  the  thickest  knitting-cotton  ; 

Esmarch's  chloroform-mask  (Fig.  221)  ; 

Garrigues's  transfusion  and  infusion  apparatus  ; 

Linen  tape,  one-fourth  inch  wide,  for  fillets  ; 

Olivier' s  fillet-carrier  ; 

Two  flexible  Enghsh  bougies  (No.  10),  for  induction  of  premature  labor  ; 

A  flexible  English  catheter  (No.  6),  for  the  larynx  of  the  child  ; 

A  soft-rubber  catheter  (No.  9),  for  the  bladder  of  the  mother  ; 

A  flexible  metal  male  catheter  ; 

A  repositor,  for  the  prolapsed  cord  ; 

A  long,  curved  intra-uterine  forceps  ; 

Two  long  artery- forceps  ; 

A  pair  of  cervical  scissors  ; 

A  sharp-pointed  bistoury  ; 

A  probe-pointed  bistoury  ; 

Simpson's  axis-traction  forceps  ; 

Simpson's  cranioclast ; 

Thomas's  perforator  ; 

Naegele's  perforator  ; 

Symphyseotomy  instruments  :  Galbati's  falcetta,  convex  and  concave  bistoury, 
and  chain  saw  ; 

A  placenta- forceps  ; 


CONDUCT    OF    NORMAL    LABOR.  185 

A  large  dull  wire  curette  ; 

Large  curved  needles  ; 

A  needle-holder  ; 

Aseptic  silkworm  gut  and  silk  ; 

A  spring  baby  scale. 

With  this  instrumentarium  I  am  prepared  for  all  operations  except 
cephalotripsy,  the  cephalotribe  being  hardly  ever  needed  and  being 
too  long  for  the  satchel  and  too  heavy  to  carry  around. 

In  the  bottles  I  have  : 

1.  Tinctura  saponis  viridis  ; 

2.  Lysol ; 

3.  Alcohol,  95  per  cent.  ; 

4.  Aqua  ammoni*  fortior  ; 

5.  Extractum  ergotfe  fluidum  ; 

6.  Liquor  ferri  chloridi  ; 

7.  Chloroform  ; 

8.  Spiritus  aetheris  compositus. 

The  satchel  with  all  its  contents  weighs  only  thirteen  and  a  half 
pounds. 

The  above  list  represents  the  outfit  of  a  specialist.  The  general 
practitioner  needs  much  fewer  instruments,  but  a  nail-brush,  a  syringe, 
an  obstetric  forceps,  needles,  needle-holder,  sewing  materials,  and  ergot 
ought  always  to  be  in  his  satchel. 

Ideas  about  what  is  necessary  differ  much.  In  a  recent  journal 
article  an  enthusiastic  disinfecter  asks  the  patient  to  provide  an  aseptic 
outfit  costing  from  four  to  thirty  dollars,  and  recommends  the  physician 
to  carry  an  obstetric  case  weighing  twenty-five  pounds  and  costing  so 
much  that  the  price  is  not  even  mentioned.  I  doubt  that  many  young 
doctors  at  the  stage  when  expenses  are  many  and  receipts  few  will  be 
willing  to  follow  this  recommendation,  and  that  they  will  have  many 
patients  with  so  long  a  purse  that  they  safely  can  propose  so  expensive 
a  preparation  for  an  event  which  forms  part  of  woman's  normal 
life.  It  is  much  more  likely  that  the  practitioner  will  have  to  carry  all 
he  needs  in  his  satchel,  and  then  it  is  important  to  him  that  this 
does  not  weigh  too  heavily  either  in  his  hand  or  in  his  accounts.  If 
we  ask  too  much,  we  shall  not  obtain  anything.  Most  general  prac- 
titioners— not  to  speak  of  midwives — are  far  trom  taking  the  most 
indispensable  antiseptic  precautions.  I  think,  therefore,  that  we  had 
better  try  to  convince  them  of  the  value  of  an  antiseptic  treatment 
which  can  be  carried  out  in  nearly  every  house  and  at  very  small  cost. 
To  ask  for  a  whole  aseptic  outfit  seems  to  me  inexpedient  and  even 
superfluous.  It  may  seem  very  simple  only  to  ask  for  a  thermometer 
registering  200°  F.  in  order  to  be  sure  to  have  heat  enough  to  sterilize 


186  NORMAL   LABOR. 

pads  ill  the  oven  of  the  kitchen  range  and  on  the  other  hand  not  to 
scorcli  them,  but  such  a  thermometer  is  not  found  in  common  dweU- 
ings,  most  people  would  not  know  how  to  read  it,  they  vrould  be  likely 
to  break  it,  and  the  doctor  has  not  time  to  pass  an  hour  in  the  kitchen 
for  sterilization  purposes.  In  private  practice  the  writer  thinks  we 
should  chiefly  he  satisfied  with  antiseptic  obstetrics  and  not  aim  at  an 
asepsis  which  gives  endless  trouble,  which  most  of  the  time  will  be 
found  impossible,  and  which  is  not  necessary  for  perfectly  satisfactory 
results.  Fortunately,  an  accouchement  does  not  require  the  same 
j3recautions  as  a  hysterectomy.  Patients  whom  we  strongly  recom- 
mend for  the  latter  to  repair  to  a  hospital,  with  all  its  perfect,  but 
costly,  paraphernalia  and  skilled  assistants,  want  to  give  birth  to  their 
children  in  their  own  homes,  in  their  common  beds,  and  with  a  rea- 
sonable outlay  of  money.  There  is,  of  course,  no  objection  to  the 
boiling  of  instruments,  and  it  is  not  necessary  to  do  so  for  an  hour. 
If  a  handful  of  washing-soda,  which  is  found  in  nearly  every  house, 
is  added  to  the  water,  a  pair  of  forceps  can  be  disinfected  in  two 
minutes.  But  to  have  sterilized  towels,  sheets,  and  aprons  is  not 
feasDDle  in  a  private  house  under  ordinary  circumstances. 

When  the  physician  answers  a  call  to  a  labor  case,  he  should  take 
his  satchel  along,  but  if  possible  he  should  leave  it  in  another  room 
in  order  not  to  scare  the  patient.  He  should  avoid  any  appearance 
of  hurry ;  and,  unless  there  are  signs  of  urgency,  he  should  first  of 
all  say  a  few  kind  words  to  the  patient,  and  do  everything  in  his 
power  to  concilitate  her  friends  and  nurse.  It  may  be  of  vital  im- 
portance to  avoid  any  friction  among  the  participants  in  the  treatment. 
Even  if  the  mother  seems  foolish  and  the  nurse  ignorant,  their  confi- 
dence and  good  graces  must  be  won,  for  there  is  no  telling  what  may 
happen  in  a  confinement  case.  When  it  is  easy,  it  is  the  easiest  thing 
in  the  world  ;  but  when  difficult,  it  is  one  of  the  most  difficult  problems 
to  deal  with ;  and  we  may  need  the  help  of  every  one  in  the  room. 

Preparation  of  the  Bed. — If  we  have  the  choice,  a  single  bed  is 
much  more  convenient  for  obstetric  purposes  than  a  double  one. 
Under  all  circumstances  it  should  be  placed  so  as  to  be  accessD^le  from 
at  least  three  sides.  The  large  above-mentioned  sheet  of  rubber  or 
oil-cloth  is  pinned  immediately  to  the  mattress,  overlapping  the  outer 
edge  of  it, — that  is  to  say,  that  turned  to  the  room  and  away  from  the 
nearest  wall.  Next  the  common  white  sheet  is  spread  over  the  whole 
bed  and  tucked  in  as  usual.  Next  the  smaller  sheet  of  rubber  or 
oil-cloth  is  put  loose  over  the  middle  of  the  sheet,  near  to  the  outer 
edge.  On  that  is  laid  a  folded  quilt  or  a  couple  of  small  quilts,  and 
on  top  of  that  a  folded  clean  sheet. 

Frejjamtion  of  the  Pcdient. — The  patient  should  wear  a  woollen 
or  merino  vest,  a  night-gown,  and  woollen  stockings  going  up  over  the 


CONDUCT    OF   NORMAL   LABOR.  187 

knees,  but  no  drawers.  The  night-gown  should  be  folded  up  under 
her  back  so  as  to  prevent  it  from  getting  soiled.  Experienced  nurses 
know^  also  how  to  pin  a  sheet  to  it  as  a  further  protection,  and  leaving 
the  whole  abdomen  and  back  from  the  ribs  downward  uncovered. 
The  patient  should  be  covered  with  a  sheet  and  enough  blankets  or 
quilts  to  feel  comfortably  w^arm.  Feather-beds,  unless  in  the  shape 
of  cpiilts,  are  inconvenient,  owing  to  their  bulk  and  w-eight.  When 
circumstances  allow  it,  it  is  well  to  let  the  patient  at  the  beginning 
of  labor  take  a  general  Avarm  bath  and  scrub  her  with  soap,  in  order 
to  have  the  skin  in  as  good  condition  as  possible  in  regard  to  cleanli- 
ness and  perspiration.  If  labor  has  progressed  so  far  that  there  is 
considerable  dilatation  of  the  os,  especially  in  a  multipara  with  a 
gaping  vulva,  it  is  better  not  to  give  a  bath,  as  the  water  might  enter 
the  genital  canal  and  become  a  source  of  infection. 

An  enema  of  soapsuds  should  be  given.  This  may  conveniently 
be  prepared  by  stirring  a  cake  of  any  kind  of  soap  with  a  tablespoon 
in  a  pitcher  of  lukewarm  water  until  a  good  lather  forms.  It  is  best 
to  administer  it  with  a  Davidson's  bulb  and  valve  syringe,  as  the 
interrupted  jets  contribute  to  call  forth  a  movement  of  the  bowels. 
The  object  in  giving  this  enema  is  twofold  :  first,  w^e  thereby  avoid 
the  disgusting  and  sometimes  even  dangerous  evacuation  of  faeces  into 
the  bed  and  over  the  accoucheur's  hands,  and,  secondly,  we  give  more 
room  for  the  foetus  to  pass  the  pelvis. 

The  patient  should  be  near  the  right  edge  of  the  bed,  so  as  to 
facilitate  all  movements  of  the  accoucheur's  right  hand. 

Abdominal  Palpation. — We  have  above  (pp.  107-120)  given  full 
information  as  to  how  a  complete  physical  examination  of  a  pregnant 
woman  should  be  made.  During  labor  there  are  three  w^ays  of  seek- 
ing the  information  needed  in  order  to  be  able  to  give  proper  assist- 
ance to  the  parturient  woman, — abdominal  palpation,  auscultation, 
and  vaginal  examination.  By  abdominal  palpation  Ave  ascertain,  first 
of  all,  if  she  is  pregnant ;  secondly,  we  learn  whether  it  is  a  longitu- 
dinal or  a  cross  presentation  ;  thirdly,  w^e  make  out  where  the  head  is  ; 
fourthly,  we  map  out  the  whole  child,  calculating  its  size  and  forming 
an  idea  whether  the  back  is  turned  forward  or  backward,  to  the  left  or 
to  the  right  side  of  the  patient ;  and,  finally,  we  judge  of  the  size  of  the 
head  and  its  degree  of  engagement  in  the  pelvic  cavity.  In  making  his 
palpation  the  accoucheur  should  also  be  on  the  lookout  for  the  more 
common  abnormalities,  such  as  twins  or  abdominal  tumors. 

By  means  of  the  stethoscope  we  find  the  locality  of  the  greatest 
intensity  of  the  fetal  heart-sound,  and  may  also  listen  for  the  uterine 
souffle  and  the  umbilical-cord  sound,  although  they  are  of  minor 
practical  importance.  The  accoucheur  should  first  apply  his  stetho- 
scope about  two  inches  to  the  left  of  and  below  the  umbilicus,  which 


188  NORMAL   LABOR. 

is  the  most  common  place  for  the  heart-sound  to  be  heard,  and,  as 
a  rule,  corresponds  to  the  left  occipito-anterior  position  and  vertex 
presentation. 

Disinfection. — Before  the  physician  proceeds  any  farther  in  his 
examination,  he  and  the  patient  must  be  especially  prepared  in  regard 
to  the  possibility  of  infection,  and  if  the  doctor  will  remember  in  every 
single  case  that  his  patient's  health  and  life  and  his  own  reputation 
are  at  stake,  he  will  pay  the  closest  attention  to  the  performance  of 
this  part  of  his  duty. 

The  abdomen,  thighs,  and  buttocks  of  the  patient  are  washed  with 
soap  and  hot  water,  using  a  towel  or  a  piece  of  muslin.  The  external 
genitals,  inclusive  of  the  inside  of  the  vulva,  are  washed  in  a  similar 
way,  using  absorbent  cotton.  After  that,  all  these  parts  are  gone 
over  again  with  lysol  solution. 

The  doctor  should  pull  off  his  coat,  vest,  collar,  necktie,  and 
cuffs,  and  turn  up  the  sleeves  of  his  shirt  and  undershirt  above  the 
elbows.  A  folded  sheet  should  be  pinned  around  his  body  and  to  his 
suspenders,  reaching  from  his  armpits  to  his  feet.  Next  he  should 
scrub  his  hands  and  arms  with  soap  and  as  hot  water  as  he  can  bear 
for  three  minutes,  using  his  own  nail-brush,  and,  having  rinsed  them,, 
he  should  scrape  his  nails  with  a  steel  nail-scraper,  removing  every 
vestige  of  dirt  that  still  may  remain  under  them.  Thereafter  he  should 
scrub  his  hands  and  arms  for  three  minutes  more  in  a  one  per  cent, 
solution  of  lysol  (a  teaspoonful  for  each  pint  of  water),  and,  finally, 
he  should  wash  them  with  alcohol  and  absorbent  cotton.  In  thus 
disinfecting  his  hands  he  should  take  particular  care  to  clean  the  fur- 
row at  the  base  and  sides  of  the  nails  and  the  space  under  their  tips. 

Only  when  all  this  has  been  attended  to  are  physician  and  patient 
in  a  fit  condition  for  a  vaginal  examination.  The  patient  should  He 
on  her  back,  near  the  edge  of  the  bed  ;  the  accoucheur  should  sit  on 
a  chair  close  up  to  the  bed.  The  nurse  should  lift  the  bedclothes,  so 
as  to  afford  free  access  to  the  genitals  without  touching  any  other 
object.  The  doctor  should  open  the  vulva  widely  with  the  left  hand 
and  introduce  the  right  index-finger  through  the  vagina  to  the  os.  He 
notices  the  position  and  length  of  the  cervix,  the  size  of  the  os,  whether 
the  ovum  is  ruptured  or  not,  what  the  presentation  is,  and  perhaps 
the  position.  He  feels  whether  the  head  is  engaged,  and  if  so  how 
deep  it  dips  into  the  pelvic  canal,  in  which  respect  the  symphysis 
pubis,  the  ihopectineal  line,  the  spine  of  the  ischium,  and  the  tip  of  the 
coccyx  are  used  as  landmarks.  By  placing  the  finger  on  the  head  and 
seizing  it  above  the  symphysis  between  the  thumb  and  index-finger  of 
the  left  hand,  he  can  judge  accurately  of  its  size.  He  should  not  enter 
the  cervical  canal.  Only  in  abnormal  cases  there  may  be  call  for  in- 
ternal pelvimetry  with  two  fingers  (p.  116)  or  even  an  examination 


CONDUCT    OF   NORMAL    LABOR.  189 

with  "half  the  hand,'" — that  is,  with  all  four  fingers  and  the  meta- 
carpus up  to  the  thumb.  In  normal  cases  he  should  l)e  satisfied  with 
what  he  feels  through  the  cervix  and  lower  uterine  segment  and  in 
the  open  os.  He  feels  for  the  posterior  fontanelle  and  the  sagittal 
suture,  the  direction  of  which  at  once  indicates  the  position  of  the 
head  in  the  pelvis.  In  the  first  position  the  posterior  fontanelle  is 
felt  pointing  forward  and  to  the  left,  and  the  sagittal  suture  running 
backward  in  the  right  oblique  diameter.  In  the  second  position  the 
small  fontanelle  points  forward  and  to  the  right,  and  the  sagittal  suture 
follows  the  left  oblique  diameter  of  the  pelvis. 

Some  obstetricians  condemn  the  internal  examination  altogether, 
and  there  is  no  doubt  that  infection  chiefly  takes  place  in  consequence 
of  this  examination.  In  preantiseptic  times  it  was  a  well-known  fact 
that  street-births  took  a  particularly  smooth  and  uneventful  course. 
The  patient,  being  suddenly  taken  in  labor,  and  giving  birth  to  her 
child  without  the  help  of  any  midwife  or  doctor,  was  sheltered  from 
the  chief  cause  of  puerperal  disease.  But  with  our  present  knowledge 
and  means  of  disinfection,  the  dangers  of  infection  have  been  mini- 
mized, and,  on  the  other  hand,  the  internal  examination  offers  so  valu- 
able information  about  the  progress  of  labor,  presentation,  position, 
and  abnormalities  calling  for  interference,  that,  in  the  opinion  of  the 
writer,  the  advantages  outweigh  the  danger.  But  since  it  is  impossi- 
ble to  produce  absolute  sterilization  of  the  skin,  and  since  there  may 
be  pathogenic  germs  in  the  vulva  and  vagina,  the  rules  given  above 
should  be  carefully  followed,  and  furthermore  internal  examinations 
should  be  restricted  as  much  as  possible, — that  is,  they  should  only 
be  repeated  with  one  or  two  hours'  interval. 

In  cases  in  which  it  becomes  necessary  often  to  enter  the  vagina, 
it  would  be  too  troublesome  to  go  through  the  whole  process  of  dis- 
infection every  time,  but  a  basin  with  lysol  (one  per  cent.)  should  con- 
stantly be  within  reach  and  the  accoucheur  should  immerse  his  hands 
in  the  fluid  and  spread  the  labia  wide  apart  before  inserting  his  finger. 

In  order  to  avoid  spoiling  the  carpet,  it  is  well  to  direct  the  patient 
to  provide  an  old  rug,  canvas,  or  similar  substance,  to  be  placed  on 
the  floor  in  front  of  the  bed. 

It  is  a  delicate  point  to  decide  what  the  physician  should  do  if 
besides  a  patient  who  expects  to  be  confined  he  has  others  suffering 
from  diseases  which  are  catching  and  particularly  dangerous  for  a  par- 
turient woman,  such  as  diphtheria,  erysipelas,  or  pelvic  inflammation 
after  confinement.  In  preantiseptic  times  it  was  the  rule  to  place  the 
patient  to  be  confined  under  the  care  of  another  physician.  In 
lying-in  hospitals,  where  in  olden  times  so-called  epidemics  raged 
that  cost  many  lives  and  often  necessitated  the  temporary  closure  of 
the  hospital,  and  where,  on  the  other  hand,  there  is,  as  a  rule,  an 


190  NORMAL   LABOR. 

abundance  of  space  and  help,  any  patient  taken  seriously  ill  should 
be  isolated  and  have  a  special  accoucheur  and  special  nurses,  who 
are  not  allowed  to  enter  the  wards  occupied  by  waiting  women  or 
normal  puerperal  cases.  In  polychnic  service, — that  is,  where  doc- 
tors are  sent  from  a  hospital  to  treat  patients  in  their  own  homes, 
— a  similar  system  is  followed.  But  in  private  practice  it  is  very 
inconvenient  and  often  impossible  to  adopt  these  measures.  There 
may  be  only  one  physician  in  the  place,  and  in  a  time  like  ours,  when 
the  profession  complains  so  bitterly  of  the  difficulty  in  making  a  living, 
it  would  indeed  be  a  hardship  if  the  doctor  engaged  to  assist  a  woman 
in  her  confinement  were  prevented  from  answering  her  call  because 
he  had  a  case  of  contagious  disease  in  his  practice.  But  under  such 
special  circumstances  he  should  take  particular  precautions.  If  pos- 
sible, he  should  change  his  clothes  after  having  seen  the  contagious 
case,  and  even  take  an  entire  bath  with  two  drachms  of  corrosive  sub- 
limate, and  wash  his  hair  with  a  saturated  solution  of  boric  acid ;  and 
he  should  at  all  events  disinfect  his  hands  and  arms  with  more  than 
usual  care.  Before  using  lysol  and  alcohol,  it  is  well  to  use  chlorine, 
which  can  easily  be  obtained  by  taking  a  little  chlorinated  lime  and 
carbonate  of  potassium  in  the  hollow  of  the  hand  and  making  a  paste 
of  them  Avith  water,  which  paste  is  rubbed  all  over  the  parts  that  are 
to  come  in  contact  with  the  genitals  of  the  patient.  After  that  they 
may  be  scrubbed  \Yiih  a  solution  of  bichloride  of  mercury  (1  :  1000). 
If  any  odor  clings  to  the  hands,  they  should  be  washed  with  oil  of 
turpentine.  The  time  consumed  in  disinfection  should  be  prolonged 
to  ten  minutes.  But  as  in  spite  of  all  these  antiseptic  measures  it  is 
impossible  fully  to  disinfect  the  hands,  it  is  advisable  to  cover  them 
with  a  pair  of  those  thin  rubber  gloves  which  are  now  extensively 
used  by  surgeons. 

In  this  connection  it  is  also  well  to  know  that  contact  with  dead 
bodies  is  particularly  dangerous.  A  man  who  takes  obstetric  cases  or 
performs  abdominal  operations  had  better  abstain  from  making  autop- 
sies. As  we  shall  see  later,  it  was  just  the  effect  of  cadaver  poison 
on  parturient  women  which  led  to  the  understanding  of  the  cause  of 
puerperal  fever  and  to  the  discovery  of  its  prophylaxis. 

If  feasible,  it  is  also  better  to  see  parturient  women  and  well  puer- 
perae  before  attending  to  other  patients. 

After  the  accoucheur  has  made  his  examinations,  he  will  in  most 
cases  be  asked  when  the  child  will  be  born ;  but  he  should  refrain 
from  assuming  the  part  of  a  prophet,  as  it  is  impossible  to  foretell 
how  slowly  or  rapidly  labor  will  progress  and  what  complications 
may  arise.  It  is,  however,  proper  to  assure  the  patient  that  every- 
thing is  normal,  and,  if  she  is  a  primipara  without  experience,  also 
to  tell  her  not  to  expect  to  be  through  soon,  as  labor  always  is  a  slow 


CONDUCT  OF  NORMAL  LABOR.  191 

process,  especially  the  first  time.  It  would  only  make  her  impatient 
if  she  expected  to  be  delivered  in  a  few  minutes  and  had  to  face  many 
hours  of  suffering. 

Position  of  the  Patient  in  the  Three  Stages.^ — During  the  first  stage, 
if  the  waters  have  not  broken  prematurely,  the  patient  may  be  allowed 
to  be  up,  to  walk  about,  to  sit  down,  to  lean  against  some  person  or 
object, — in  fact,  to  do  as  she  likes.  When  the  os  is  nearly  dilated  or 
if  the  ovum  is  ruptured,  she  should  stay  in  bed  and  lie  on  her  back, 
but  not  too  low,  as  she  has  more  power  to  bear  down  when  the 
upper  half  of  her  body  is  somewhat  elevated.  Sometimes  it  is  a  good 
plan  even  to  take  a  strong  chair  and  place  it  in  the  bed  under  the 
patient,  padding  it  with  pillows  (Fig.  222). 

The  nurse  may  take  her  hands  and  pull  on  them  while  the  patient 
bears  down,  thus  affording  a  solid  support  during  labor-pains. 

Still  greater  force  can  be  developed  if  the  patient  pulls  on  a  rope 
fastened  to  the  lower  end  of  the  bed.  For  this  purpose  a  common 
clothes-line  may  be  used,  but  that  part  of  which  the  patient  takes 
hold  should  be  padded  by  winding  around  it  a  towel,  which  is  tied  at 
both  ends. 

In  order  to  give  a  solid  support  to  the  feet,  a  board — for  instance, 
one  of  those  lap-boards  found  in  most  houses — should  be  tied  to  the 
lower  end  of  the  bedstead,  if  it  is  composed  of  metal  bars,  and  a 
footstool  should  be  placed  between  the  board  and  the  feet  of  the 
patient. 

When  the  head  distends  the  rima  pudendi,  the  writer  turns  the 
patient  on  her  left  side  with  bent  knees,  and  deprives  her  of  all  help 
in  bearing  down  (Fig.  223).  This  is  the  position  in  England,  while 
on  the  continent  of  Europe  the  patient,  as  a  rule,  is  kept  on  her  back. 
In  the  writer's  opinion  the  left-side  position  offers  great  advantages 
over  the  dorsal.  The  genitals  are  more  accessible  and  can  be  made 
visible  while  all  the  rest  of  the  body  is  covered,  whereby  the  patient 
is  protected  against  taking  cold.  Her  pudicity  is  consulted  by  the 
mere  fact  that  she  does  not  see  the  accoucheur,  and,  as  it  were,  hides 
herself.  This  position  renders  it  possible  to  perform  certain  small 
operations,  such  as  episiotomy  and  the  application  of  serrefines,  with- 
out frightening  the  patient,  which  in  her  excited  condition  is  often 
worse  than  the  pain  incident  to  the  manipulations  themselves.  The 
voluntary  and  involuntary  use  of  the  abdominal  pressure  is  more  lim- 
ited ;  and,  most  of  all,  the  left-side  decubitus  is  useful  because  the 
fundus  sinks  down  on  the  couch,  so  that  gravitation  works  in  a  direc- 
tion almost  opposite  to  that  given  the  foetus  by  the  uterine  contrac- 
tions.    In  this  way  the  perineum  has  not  to  carry  the  weight  of  the 

'  Garrigues,  The  Best  Posture  in  the  Different  Stages  of  Labor,  Trans.  Amer. 
Gynaecol.  Soc,  1891,  vol.  xvi.  p.  188. 


192 


NORMAL   LABOR. 


baby  in  addition  to  the  pressure  exercised  on  it  by  the  uterine  and 
abdominal  contractions.  FinaUy,  this  position  facilitates  other  meas- 
ures taken  for  tlie  protection  of  tlie  perineum. 


Fig.  223. 


r 


Patient  in  left-side  position. 

Support  of  the  Perineum.  Reprression  of  the  Head. — As  a  chief 
cause  of  laceration  of  the  perineum  is  a  too  rapid  distention  of  the 
vulvar  orifice,  the  writer  prevents  the  head  from  emerging  too  sud- 
denly by  making  moderate  counter-pressure  on  the  head  during 
labor-pains  with  the  flat  hand,  especially  the  soft  muscular  cushion 
formed  by  the  ball  of  the  thumb.  To  do  it  with  the  tips  of  the 
fingers   cannot   be    recommended,   as    on   account    of  their    smaller 


CONDUCT   OF   NORMAL    LABOR.  19;3 

dimensions  and  gTeater  hardness  there  might  be  some  danger  of 
wounding  the  head,  especially  on  fontanelles  and  sutures. 

If  the  head  does  not  recede  of  itself  after  the  contraction  has 
ceased,  it  is  pushed  back  into  the  canal,  so  that  some  of  the  force  of 
the  following  contraction  is  spent  in  advancing  it  over  the  same  area, 
and  the  vulvar  opening  is  not  exposed  to  continuous  pressure.  On 
the  other  hand,  when  the  head  really  passes  the  rima,  it  may  be 
helped  out  by  pressure  in  the  direction  of  the  symphysis  pubis,  roll- 
ing the  face  over  the  perineum  and  utilizing  all  available  room  at  the 
pubic  arch.  Since  the  head  is  slippery,  all  the  manipulations  of  it  are 
much  facilitated  by  covering  it  with  a  cloth  wrung  out  of  alcohol  or 
bichloride  of  mercury  .solution,  whereas  lysol  is  too  oily  for  that 
purpose. 

Enucleation  of  the  Head. — Another  good  way  of  protecting  the 
perineum  is  to  press  the  head  out  during  an  interval  between  labor- 
pains  by  pressure  with  one  or  two  fingers  from  the  rectum.  In  so 
doing  the  accoucheur  should,  of  course,  avoid  injuring  the  eyes  of 
the  foetus ;  but  the  rectovaginal  wall  is  so  thin  that  everything  is  felt 
very  plainly.  Another  factor  to  be  borne  in  mind  is  not  to  use  so 
much  force  as  to  cause  tears  in  the  region  of  the  maternal  clitoris, 
which  may  give  rise  to  dangerous  hemorrhage. 

The  administration  of  chloroform  is  also  a  great  protection  for  the 
perineum. 

The  Shoulders. — So  far  we  have  considered  only  the  dangers 
accruing  to  the  perineum  from  the  passage  of  the  head ;  but  it  is 
threatened  as  much,  or  even  more,  by  that  of  the  shoulders.  Ex- 
amining during  the  interval  which  generally  follows  the  expulsion  of 
the  head,  the  writer  has  often  convinced  himself  that  the  skin 
between  the  posterior  commissure  and  the  anus  was  intact,  and  still 
found  a  considerable  laceration  of  this  part  after  the  birth  of  the 
child.  As  with  a  normal  child  there  is  no  longer  any  difficulty  in 
delivery  when  once  the  shoulders  have  passed,  we  must  attribute 
the  accident  to  the  passage  of  these  parts  of  the  fetal  body.  This 
is  also  easily  understood  when  we  think  of  their  different  conforma- 
tion. In  consequence  of  its  circular  circumference,  its  tapering  top, 
and  its  alternate  progression  and  retrocession,  the  head  will  in  most 
cases  open  the  vulvar  ring  gradually  and  distend  it  uniformly.  The 
combined  chest  and  shoulders,  on  the  contrary,  measure  much  more 
from  side  to  side  than  in  the  anteroposterior  direction.  The  shoulders 
contain  hard,  bony  portions  embedded  in  soft  surroundings,  they  form 
an  abrupt  projection  from  the  comparatively  thin  neck,  and  are  com- 
monly expelled  all  at  once  by  a  single  labor-pain.  All  tliese  circum- 
stances render  them  more  dangerous  than  the  head,  and  they  have 
only  the  one  advantage  of  coming  after  the  genital  canal  has  been 

13 


194  '  NORMAL   LABOR. 

dilated  by  the  latter.  We  must,  therefore,  not  think  we  are  done 
with  the  protection  of  the  perineum  because  the  head  has  been  safely- 
delivered.  Sometimes  help  may  be  afforded  by  pushing  back  the 
posterior  shoulder  a  little,  and  thereby  facilitating  the  descent  of  the 
anterior.  Or  the  anterior  shoulder  may  be  helped  down  by  hooking 
the  index-fmger  into  the  axilla  and  pulling  the  shoulder  under  the 
pubic  arch.  When  first  the  anterior  shoulder  has  passed,  it  should 
be  pressed  well  forward,  so  that  no  room  be  lost.  If  exceptionally 
there  is  a  tendency  of  the  posterior  shoulder  to  pass  first,  this  move- 
ment may  be  favored  by  inserting  the  index-finger  in  the  corre- 
sponding axilla  and  pulling  it  forward. 

The  writer  does  not  approve  of  applying  direct  pressure  to  the 
perineum,  which,  instead  of  being  protected  thereby,  is  endangered 
still  more  by  being  compressed  between  the  hard  head  of  the  foetus 
and  the  bones  in  the  hand  of  the  accoucheur.^ 

Compression  of  the  Uterus. — If  the  contractions  of  the  uterus  are 
normal,  no  pressure  should  be  exercised  on  it,  as  this  would  over- 
stimulate  the  organ,  and  might  lead  to  later  exhaustion  or  cause  injury 
to  the  genital  canal,  especially  the  vaginal  entrance  and  perineum. 
Compression  after  delivery  is,  on  the  contrary,  very  useful,  and  will 
presently  be  considered.  Moderate  pressure  on  the  fundus  uteri  is 
also  allowable  if  the  contractions  of  the  uterus  and  abdominal  muscles 
are  defective. 

The  head  must  under  no  circumstances  be  pulled  on  in  the  attempt 
to  help  out  the  shoulders.  All  that  may  safely  be  done  is  to  hold  it 
between  the  flat  hands  and  press  it  a  little  upward  or  downward.  As 
a  rule,  I  do  not  touch  it  after  once  it  is  outside  of  the  genital  canal. 

Liberatio7i  of  the  Umbilical  Cord. — At  this  stage  the  accoucheur 
should  ascertain  whether  the  cord  is  wound  around  the  neck,  and,  if 
so,  whether  one  of  the  ends  yields  on  moderate  traction.  As  soon 
as  the  loop  becomes  large  enough  he  should  pull  it  over  the  head  of 
the  foetus,  but,  if  he  meets  with  too  much  resistance,  he, should  tie 
the  cord  with  two  ligatures  an  inch  apart  and  cut  it  with  blunt-pointed 
scissors. 

When  the  shoulders  are  born,  there  is  no  more  resistance  ;  but, 
since  according  to  law  the  child  is  not  born  and  has  no  right  as  such 
until  its  %ohole  body  is  outside  of  the  mother,  I  am  in  the  habit  of 
pulling  it  out. 

Next  the  mother  should  be  turned  on  her  back,  as  the  dorsal 
decubitus  is  much  better  than  the  left-side  position  during  the  third 
stage  of  labor.     She  lies  with  bent  knees,  and  the   child  is  placed 

^  The  writer  has  entered  more  in  detail  into  the  question  of  "The  Obstetric 
Treatment  of  the  Perineum"  in  an  article  pubUshed  in  the  American  Journal  of 
Obstetrics,  vol.  xiii.,  No.  11,  April,  1880. 


CONDUCT    OF   NORMAL   LABOR. 


195 


transversely  in  front  of  her  genitals.  The  accoucheur  needing  both  his 
hands,  the  nurse  should  take  hold  of  the  uterus,  with  four  fingers 
behind  and  the  thumb  in  front  (Fig.  224),  and  compress  it  firmly. 


Fu4.  224. 


Child  placed  transversely  m  front  of  mother's  genitals,  nurse  compressing  the  uterus,  doctor 

cutting  the  cord. 


Tying  and  Cutting  the  Cord. — The  accoucheur  should  now  take  the 
umbilical  cord  gently  between  his  thumb  and  index-finger,  and  when 
pulsation  stops  he  should  tie  the  cord  and  divide  it  with  scissors. 
The  cutting  is  done  in  the  way  Avhich  is  most  convenient  for  the  doctor 
and  safest  for  the  baby  by  holding  the  cord  between  the  thumb  and 
the  ring-finger  in  front  and  between  the  index  and  the  middle  finger 
behind,  and  cutting  between  the  fingers.  For  the  ligation  of  the  cord 
I  prefer  the  thickest  ball  cotton,  taken  double,  which  is  soft,  strong, 
and  sufficiently  wide.     Two  ligatures  are  used.     I  tie  the  two  ends 


196  NORMAL  LABOR. 

of  each  together,  and  make  the  double  thread  about  twelve  inches  long. 
Before  placing  it  around  the  cord,  the  accoucheur  should  satisfy  him- 
self that  the  abdomen  is  closed  and  that  no  part  of  the  intestine  lies  in 
the  cord.  After  having  found  everything  normal,  he  places  his  first 
ligature  around  the  cord  about  three-quarters  of  an  inch  from  the  skin. 
This  ligature  should  be  well  tightened,  especiaUy  if  the  cord  is  "fat," 
since  its  role  is  to  close  the  three  vessels  of  the  umbilical  cord.  I  take 
only  half  a  hitch  on  one  side,  bring  the  ligature  around  on  the  other 
side,  take  another  half  hitch,  tighten  again,  and  then  tie  the  ends  in  a 
double  bow.  The  second  ligature  is  placed  around  the  cord  an  inch 
nearer  to  the  mother,  and  simply  tied  in  a  knot,  and  then  the  cord  is 
cut  midway  between  the  two  ligatures  (Fig.  224). 

A  few  words  will  explain  why  these  little  things  are  done  in  this 
way  and  not  otherwise.  By  waiting  till  pulsation  stops  in  the  cord 
we  allow  a  certain  amount  of  blood,  which  otherwise  would  remain 
in  the  placenta  and  to  which  the  child  has  a  natural  right,  to  be  pro- 
pelled into  its  body. 

By  making  the  stump  of  the  cord  short  we  avoid  an  undesirable 
leverage,  a  dried-up  stump  three  finger-breadths  long  being  pulled 
hither  and  thither  by  the  bandage  and  perhaps  broken  off  prema- 
turely. We  also  obtain  the  advantage  of  having  less  decaying  material 
in  connection  with  the  child. 

We  put  on  the  first  ligature  with  great  care  and  tie  it  in  a  bow  so 
that,  if  on  later  inspection  it  proves  not  to  be  tight  enough,  but  to 
allow  some  oozing  of  blood,  we  may  easily  tighten  it.  The  second 
ligature  serves  only  to  arrest  bleeding  from  the  placenta,  which  will 
be  thrown  off  in  a  few  minutes.  It  is  chiefly  put  on  for  cleanli- 
ness' sake,  so  as  not  to  have  the  placental  blood  soil  the  bed ;  but 
a  second  reason  for  using  it  is  that  there  may  be  a  second  child 
connected  with  the  same  placenta,  which  might  bleed  to  death  from 
loss  of  blood. 

If  the  cord  is  very  thick,  it  is  well  to  press  some  of  the  gelatin  of 
Wharton  in  the  direction  of  the  mother  before  tying  the  cord. 

When  the  cord  has  been  tied,  the  child  is  wrapped  up  in  a  warm 
piece  of  flannel,  and  outside  of  that  a  shawl,  quilt,  or  blanket.  The 
whole  child  should  be  covered,  inclusive  of  the  head,  just  leaving  a 
little  opening  to  give  access  to  air.  New-born  children  do  not  need 
much  air,  but  they  are  very  sensitive  to  cold.  Having  placed  the 
child  in  a  safe  place  at  the  lower  end  of  the  bed,  the  accoucheur  re- 
turns to  the  mother.  He  now  relieves  the  nurse  in  compressing  the 
uterus. 

Expression  of  the  Placenta  (Fig.  225). — If  the  uterus  is  not  well 
contracted,  he  should  move  the  abdominal  wall  over  the  fundus  from 
side  to  side  and  grasp  the  uterus  tightly.     If  all  is  normal,  he  just 


CONDUCT   OF   NORMAL   LABOR. 


197 


holds  the  uterus  in  the  hollow  of  his  hand.  When  ho  feels  a  new 
strong  contraction  come  on, — a  so-called  after-pain, — he  should  place 
his  eight  fingers  beliind  the  uterus  aud  the  two  thumbs  in  front,  and 
during  the  pain  squeeze  the  uterus  like  a  lemon.     When  the  pain 

Fig.  225. 


Expression  of  the  placenta. 

ceases,  he  stops  squeezing  and  again  holds  tlie  nivriis  wiHi  the  left 
hand,  waiting  quietly  for  the  next  pain  to  come  on,  Avlien  he  repeats 
the  squeezing  with  both  liands.    At  the  third  or  four! h  pain  tlie  placenta 
rolls  out  into  the  bed,  retained  only  by  the  inverled  membranes. 
This  is   essentially  the    method   invented   by  Crede,  of  Leipsic. 


198  NORMAL  LABOR. 

Still  there  are  some  differences.  Crede  seized  the  uterus  with  only- 
one  hand  and  pushed  it  in  the  direction  of  the  hollow  of  the  sacrum, 
wherefore  the  adversaries  of  his  method  say  that  he  did  not  loosen 
the  placenta,  but  pressed  it  down  to  the  vaginal  entrance  and  out 
through  the  rima  pudendi,  using  the  empty  uterus,  which  is  hardened 
by  massage,  to  press  with.  In  my  opinion  this  is  a  mistake.  At 
least  I  know  for  sure  that  by  my  modification  of  the  method  I  squeeze 
the  placenta  out  of  the  womb,  and  it  is  likely  that,  by  increasing  the 
contractile  power  of  the  musculature  of  the  uterus,  I  aid  it  in  throwing 
off  the  placenta.  The  pressure  against  the  sacrum  appears  to  me 
unnatural  and  apt  to  do  harm  by  loosening  the  connection  between 
the  uterus  and  the  pelvis,  whereas  the  squeezing  imitates  and  sustams 
nature.  I  differ  from  Crede  also  in  regard  to  the  time  when  the  pla- 
centa is  expressed.  According  to  him,  the  sooner  it  is  done  the 
better,  and  he  gave  four  and  a  half  minutes  as  the  average  time  for 
the  expression.  In  my  experience  so  early  an  expulsion  leads  to 
retention  of  membranes  and  to  hemorrhage.  In  the  way  I  use  the 
method  it  takes  from  fifteen  to  twenty  minutes.^ 

When  the  placenta  rolls  into  the  bed,  part  of  the  inverted  mem- 
branes accompanies  it.  The  portion  thus  extruded  should  be  seized 
with  both  hands,  while  the  compression  of  the  now  empty  uterus  is 
again  left  to  the  nurse,  and  the  placenta  is  turned  slowly  round  so  as 
to  form  a  kind  of  rope  of  the  membranes.  In  so  doing  the  accoucheur 
should  bear  in  mind  that  the  thin,  elastic  membranes  cannot  be 
thrown  off  like  the  thick,  blood-filled  placenta.  They  still  adhere  to 
the  lower  part  of  the  inside  of  the  uterus.  If  the  rope  is  twisted  too 
fast,  the  membranes  Avill  be  torn  off,  which  may  give  rise  to  severe 
hemorrhage  and  necessitate  the  introduction  of  the  hand  into  the 
uterine  cavity  in  order  to  remove  the  retained  portion.  The  placenta 
should,  therefore,  be  rotated  very  deliberately,  and  the  rope  should 
not  be  seized  between  the  thumb  and  the  index-finger,  as  then  we 
might  exercise  undue  force,  but  only  between  the  index  and  the 
middle  finger,  alternately  placing  one  hand  behind  the  other,  until 
the  last  end  of  the  ovum  is  slowly  pulled  out  (Fig.  226).  The  pla- 
centa and  membranes  together  are  called  the  cifter-birth,  or  secundines. 

When  the  after-birth  has  been  removed,  the  doctor  should  care- 
fully inspect  it  and  satisfy  himself  that  nothing  has  been  left  behind. 
Then  it  is  temporarily  deposited  in  a  clean  chamber-pot,  and  later 
buried  or  burnt  in  the  range,  but  not  cast  into  a  water-closet,  the 
pipes  of  which  it  would  block  up. 

^  Some  details  about  the  three  different  metliods  of  removing  the  after-birtli — 
by  pulling  on  the  cord,  by  compressing  the  uterus,  and  by  leaving  the  Avhole  third 
stage  to  nature — are  found  in  my  paper  on  "Removal  of  the  After-birth,"  Amer. 
Jour.  Obst.,  A'ol.  xvii.,  No.  5,  1884. 


COXDUCT    OF   NORMAL   LABOR. 


199 


Next  the  perineum  should  be  exammed,  and  if  it  is  torn  it  should 
be  stitched.  Then  the  patient  should  be  cleaned,  and  as  this  is  an 
important  part  of  the  whole  act,  during  which  the  patient  might  be 
infected,  it  is  much  better  that  the  accoucheur  should  attend  to  it 


Fig.  226. 


Extraction  of  the  membranes. 


himself  than  leave  the  performance  of  this  duty  to  the  nurse  ;  but 
while  the  doctor  does  the  cleaning,  the  nurse  should  continue  to  hold 
the  uterus  moderately  compressed  M-ith  one  hand.  I  usually  tear  off 
three  pieces  of  unbleached  muslin,  and  wash  all  soiled  parts  of  the 
skin  with  lysol  water  and  wipe  them  dry  with  clean  towels.  The  in- 
terior of  the  genitals  should  not  be  touched,  but  the  mons  Veneris 
and  the  outside  of  the  labia  should  be  washed  with  absorbent  cotton 


200 


NORMAL   LABOR. 


dipped  in  lysol  water.     If  the  pubic  hairs  are  matted  together  with 
blood-clots,  it  is  better  to  cut  off  some  of  them. 

Abdominal  Binder. — When  the  woman  has  been  washed  and 
wiped  dry,  certain  bandages  should  be  applied.  The  writer  impro- 
vises these  himself  at  the  time  they  are  to  be  put  on.  First  comes  the 
binder,  a  piece  of  unbleached  muslin  long  enough  to  go  once  around 
the  abdomen  and  overlap  a  little,  and  wide  enough  to  extend  from 
the  trochanters  to  the  ensiform  process.  The  unbleached  muslin 
ordered  being  a  yard  wide,  I  double  it  lengthwise,  put  the  fold  down- 
ward, and  tear  off  the  superfluous  tissue  at  the  upper  end.  This 
binder  is  drawn  tightly  together  in  front  of  the  lower  part  of  the 
abdomen,  leaving  the  ends  free.  Next  I  go  upward,  always  tighten- 
ing the  binder  and  inserting  large  safety-pins  perpendicularly,  so  as 

to  place  them  at  right  angles 
Fig.  227.  to  the  direction  in  which  the 

bandage  would  open.  When 
the  waist  is  reached,  a  fold  is 
taken  in  on  each  side  and 
fastened  with  a  pin,  and 
finally  one  or  two  more  are 
placed  in  the  median  line.  A 
good  nurse  can  pin  such  a 
binder  very  accurately,  fold- 
ing in  the  free  end  of  the 
binder  and  using  a  large  num- 
ber of  bank-pins,  which  she 
places  transversely  at  short 
intervals  from  one  another. 
Such  an  arrangement  looks 
very  pretty,  but  for  practical 
purposes  half  a  dozen  large 
safety-pins  placed  lengthwise  suffice.  We  return  now  to  the  lower 
ends  and  fold  the  free  flaps  in  so  as  to  have  a  A-shaped  opening  in 
front  of  the  pubes  (Fig.  227). 

Garrigues's  Ocdusion-Dressing. — Next  we  apply  a  pad  to  the 
perineum  (Fig.  228,  A).  This  consists  of  four  parts, — an  absorbent 
inner  portion,  a  water-proof  middle  layer,  a  third  layer  to  give  bulk, 
and  an  outer  layer  to  keep  all  in  place.  Innermost  there  is  an  oblong 
made  either  of  absorbent  lint  eight  inches  long  and  three  inches  wide, 
four  layers  thick,  or  a  pad  of  absorbent  cotton  formed  so  as  to  have 
similar  proportions,  which  correspond  to  the  distance  between  the 
genitofemoral  furrows  and  the  length  of  the  perineum.  The  lint  or 
cotton  is  wrung  out  of  lysol  water.  Outside  of  this  absorbent  ma- 
terial comes  a  piece  of  gutta-percha  tissue  (Fig.  228,  7?),  an  inch  wider 


Abdomiual  biuder. 


CONDUCT    OF    NORMAL    LABOR. 


•H)] 


and  longer  than  the  former.  It  is  washed  in  lysol  water  and  bent 
forward  against  the  inside  of  the  thighs.  Outside  of  this  is  placed 
a  piece  of  muslin,  half  a  yard  square  and  folded  like  a  cravat  (Fig. 
228,  C)  so  as  to  be  five  inches  wide.     Inside  lies  some  cotton,  and 


/5m. 


Garrigues's  perineal  pad. 

the  ends  are  folded  in  so  as  tf)  make  the  oblong  about  fifteen  inches 
long  (Fig.  228,  IJ).  This  is  pinned  to  the  binder  with  four  small 
safety-pins  in  front,  placed  transversely  and  occluding  the  A-shapcd 
opening  left,  and  two  similar  pins  behind  (Fig.  229). 

It  will  be  seen  that  the  binder  forms  a  necessary  support  tor  my 
perineal  pad;  but  independently  of  that  I  am  decidedly  in  favor  of 


202  NORMAL    LABOR. 

its  use,  as  it  steadies  tlie  uterus  and  compresses  the  alDdominal  wall, 
whereby  involution  is  furthered,  and  the  unsightly  prominence  of  the 
abdomen  so  often  observed  in  women  who  have  not  been  properly 
nursed  in  childbed  is  avoided. 

Some  think  even'  kind  of  perineal  dressing  is  superfluous,  others 
just  put  a  loose  napkin  in  between  the  thighs ;  but  my  pad  has  at 
least  the  advantag-e  of  protecting  the  genitals  against  contact  with 
unclean  objects  ;  it  makes  the  patient  feel  comfortable  ;  and  it  is  very 
popular  with  the  laity  because  it  is  supposed  to  protect  the  parts 
against  cold,  this  bugbear  suspected  by  the  public  to  be  responsible 
for  almost  any  disease. 

The  principles  of  this  treatment  may  be  followed  even  ^^•hen  strict 
economy  is  imperative.  Then  common  cotton  batting  may  be  substi- 
tuted for  the  more  expensive  absorbent  cotton  in  the  outer  part  of 
the  dressing,  where  it  only  serves  to  make  bulk,  or  even,  though  less 
well,'  in  the  inner,  antiseptic,  part  of  the  pad.  Gutta-percha  tissue 
may  be  replaced  by  the  much  cheaper  oiled  muslin,  or  even  left  out 
altogether.  Instead  of  lysol  one  may  use  carbolic  acid.  In  this  way 
the  expenses  would  be  reduced  to  eight  cents  for  a  bundle  of  cotton 
batting,  thirty-six  cents  for  six  yards  of  unbleached  muslin,  ten  cents 
for  two  dozen  safety-pins,  and  forty  cents  for  eight  ounces  of  carbolic 
acid. — ninety-four  cents  in  all.  Women  who  cannot  afford  that  small 
expense  had  better  be  delivered  in  some  charitable  institution,  or  the 
doctor  may  omit  all  dressings  and  bring  with  him  some  bichloride  of 
mercury  tablets  or  carbolic  acid  for  disinfection  of  his  own  hands. 
If  the  forceps  is  used,  it  should  be  boiled. 

Preliminary  Douche. — In  former  writmgs  I  have  recommended  to 
give  a  disinfectant  vaginal  douche  before  deliver^'.  In  this  respect  I 
have  changed  my  views  and  practice,  but  there  is  much  to  be  said  on 
both  sides,  for  and  against  the  preliminary  douche.  Those  who  are 
opposed  to  it  say  that  it  has  been  proved  that  there  are  no  pathogenic 
bacteria  in  the  normal  vaginal  secretion  of  pregnant  women,  that  it 
even  has  the  power  of  killmg  microbes  experimentally  brought  in, 
that  it  is  a  useful  lubricant,  and  that  the  danger  of  carrymg  infecting 
germs  into  the  vagina  with  fingers  and  syringes  is  greater  than  the 
advantage  to  be  derived  from  the  germicidal  properties  of  the  fluid 
injected ;  and,  finally,  that  if  there  be  microbes  in  the  vagina  they  will 
not  be  removed  by  administering  a  douche. 

To  this  may  be  answered,  that  the  vaginal  secretion  frequently 
has  lost  its  normal  alkalmity  and  thereby  its  germicidal  power.  Fur- 
thermore, pathogenic  microbes  may  be  brought  in  through  coition  or 
other  contact  immediately  before  labor.  The  writer  recently  saw  a 
case  in  which  the  husband,  a.  laboring  man,  when  his  wife  complained 
of  pain,   satisfied    himself   by    vaginal    examination    every    morning 


/ 


CONDUCT   OF   NORMAL   LABOR.  203 

before  going  to  work  that  the  os  had  not  begun  to  dilate  !  The 
normal  glairy  fluid  which  lubricates  the  parturient  canal  is  poured  out 
in  abundant  quantity,  even  if  a  vaginal  douche  has  been  given  at  the 
beginning  of  labor.  If  the  douche  cannot  remove  all  the  microbes 
found  in  the  vagina,  it  may  at  least  reduce  their  number  sufficiently  to 
enable  nature  to  master  those  left.  But  since  there  is  a  real  danger 
of  infection  being  carried  by  fingers  and  instruments,  and  since  there 
is  abundant  evidence  that  the  best  results  may  be  obtained  without 
using  any  prophylactic  douche,  it  is  better  under  ordinary  circum- 
stances to  omit  it.  If,  however,  the  vaginal  discharge  is  neutral  or 
acid,  and  especially  if  it  is  purulent,  a  douche  of  two  quarts  or  more 
of  a  one  per  cent,  solution  of  lysol  or  carbolic  acid  should  be  given 
before  making  the  vaginal  examination. 

The  distrust  of  the  efficiency  of  the  douche  has  led  some  to 
recommend  instead  rubbing  or  scrubbing  of  the  vagina  as  in  pre- 
paring it  for  a  gynaecological  operation,  but,  since  this  cannot  be  done 
without  removing  the  epithelium  in  places,  such  a  procedure  is  likely 
to  do  much  more  harm  than  it  can  possibly  do  good,  and  ought, 
therefore,  to  be  deprecated. 

Catheterization. — It  is  of  great  importance  to  keep  the  bladder 
empty  or  only  slightly  filled  during  labor  and  delivery.  Braune's 
plate.  Tab.  C  (Fig.  205,  p.  169),  has  taught  us  that  during  labor  the 
whole  bladder  is  pulled  up  above  the  symphysis  and  becomes  stripped 
of  its  peritoneal  covering.  The  smaller  its  surface,  the  easier  this 
will  be  done.  Before  the  use  of  the  obstetric  forceps  had  become  so 
common  as  in  our  time,  vesicovaginal  fistulae,  involving  a  large  por- 
tion of  the  base  of  the  bladder,  were  by  no  means  rare,  and  they 
were  due  to  compression  of  the  organ  between  the  head  and  the 
symphysis.  The  viscus  being  drawn  up,  the  urethra  becomes  much 
lengthened  and  is  often  compressed,  so  that  the  patient  cannot  urinate. 

It  then  becomes  necessary  for  the  accoucheur  to  draw  the  urine, 
and,  as  the  urethra  is  so  long,  the  common  female  catheter  will  often 
be  found  too  short.  If  a  soft-rubber  catheter  can  be  passed,  it  is 
safest  of  aU  on  account  of  its  flexibility.  If  it  cannot,  a  male  metal 
catheter  should  take  its  place.  By  having  it  of  flexible  metal,  we 
obtain  the  great  advantage  that  we  may  change  the  curvature  to  fit 
each  case.  In  order  to  pass  one,  it  may,  however,  become  necessary 
to  lift  the  presenting  head  from  the  vagina.  Whatever  catheter  is 
used  should  be  disinfected  by  boiling  a  few  minutes  in  a  solution  of 
soda  (an  even  tablespoonful  to  a  quart  of  water). 

Ancesthesia.- — Every  woman  ought  to  know  the  name  of  Sir  James 
Y.  Simpson,  who  in  1847  introduced  the  use  of  chloroform  in  normal 
childbirth.  He  met  with  groat  opposition  when  he  first  advocated 
this  novelty.     The  medical  profession  thought  it  dangerous,  and  the 


204  NORMAL   LABOR. 

orthodox  clergy  found  it  sacrilegious  ;  but  science  prevailed,  and  found 
a  mighty  ally  in  no  less  a  person  than  Her  Majesty  Queen  Victoria, 
who  adopted  the  new  method  in  her  next  confinement.  So  august 
an  example  could  not  fail  to  find  numerous  imitators,  and  soon  the 
custom  spread  from  Great  Britain  over  the  whole  civihzed  world. 
Occasionally  I  meet  with  a  person  who  is  afraid  of  the  ana?sthetic  and 
prefers  to  suffer ;  but  I  have  never  seen  a  woman  in  labor  who  after 
havmg  smelted  chloroform  once  and  experienced  its  wonderful  effect 
would  do  without  it.  Some  women  give  birth  to  their  children  with 
so  little  pain  that  they  do  not  need  any  anaesthetic,  and  they  are 
rewarded  for  their  fortitude  by  a  shorter  duration  of  labor  and  greater 
safety  in  regard  to  hemorrhag-e.  Even  if  given  intelligently,  chloro- 
form prolongs  the  interval  between  uterine  contractions  and — I  do 
not  think  we  can  deny  it — predisposes  to  post-partum  hemorrhage. 
If  used  too  early  and  in  too  large  a  quantity,  it  becomes  dangerous. 
The  writer's  practice  is  to  defer  its  use  as  long  as  possible,  for  when 
once  we  begin  we  must  give  it  ever}^  tune  pain  returns,  unless  there 
arises  a  positive  counterindication  to  its  administration.  I  give  it 
always  when  the  head  appears  at  the  rima  pudendi,  but  if  the 
woman  suffers  much  I  give  it  earlier  in  the  second  stage,  never  in  the 
first. 

In  obstetric  cases  chloroform  should  be  given  in  an  entirely  dif- 
ferent way  from  that  used  in  operations.  Some  nervous  and  pusil- 
lanimous women  think  the  doctor  can  anaesthetize  them  when  they 
feel  the  first  pam,  and  keep  them  unconscious  till  the  child  is  born. 
This  would  be  exceedmgly  dangerous  for  mother  and  child,  and 
ought,  therefore,  not  to  be  thought  of  The  way  to  give  chloroform 
is  at  the  beginning  of  a  contraction  to  pour  eight  or  ten  drops  on  an 
Esmarch  mask  (Fig.  221)  and  apply  it  over  the  patient's  nose  and 
mouth.  As  soon  as  the  pain  ceases  it  should  be  removed.  It  is  only 
during  the  few  minutes  while  the  head  passes  the  rima  pudendi,  and 
when  the  pain  is  greatest,  that  the  patient  is  kept  anaesthetized  to  the 
surgical  degree  and  uninterruptedly.  As  soon  as  the  head  is  born  no 
more  chloroform  should  be  given. 

In  private  practice  hardly  any  other  antesthetic  than  chloroform  is 
used.  For  protracted  obstetric  operations,  such  as  Ctesarean  section 
or  symphyseotomy,  the  writer  prefers  ether,  as  in  all  other  operations, 
on  account  of  its  greater  safety. 

Medullary  Cocahiization. — After  the  German  surgeon  August  Bier 
had  published  ^  liis  discovery  that  anaesthesia  may  be  produced  in  the 
lower  half  of  the  body  of  man  without  causing  unconsciousness,  by 
injecting  cocaine  into  the  spinal  canal,  this  method  was  for  some  time 
used  rather  extensively  in  gynaecological  and  obstetrical  operations  and 
1  Bier,  Zeitschrift  fiir  Chiruigie,  April,  1S99. 


CONDUCT    OF   NORMAL    LABOR.  205 

even  in  normal  labor  cases.     In  this  country  it  found  an  enthusiastic 
spokesman  in  Dr.  S.  Marx.^ 

The  patient  is  placed  in  a  sitting  posture  on  a  table  and  made  to 
bend  forward  until  the  lumbar  region  forms  a  convex  curvature.  If 
she  cannot  sit  up,  she  may  lie  on  the  left  or  right  side  with  arched 
back.  The  field  of  operation  is  disinfected  as  well  as  the  operator's 
hands.  A  sterilized  needle,  ten  centimetres  (four  inches)  long,  is 
pushed  in  between  the  fourth  and  fifth  lumbar  vertebrae.  The  oper- 
ator places  his  left  thumb  on  the  spinous  process  of  the  fifth  lumbar 
vertebra  and  pushes  the  needle  in  immediately  above  and  just  outside 
of  the  nail,  in  a  direction  going  straight  forward.  He  should  push  it 
rapidly  through  the  skin,  but  thereafter  proceed  slowly.  If  it  strikes 
a  bone,  the  direction  must  be  altered  a  little.  The  needle  must 
enter  the  subarachnoid  space,  when  the  cerebrospinal  fluid  will  flow 
out  drop  by  drop.  This  is  the  only  criterion  that  the  needle  is  in 
the  right  place,  and  has  also  the  advantage  of  forcing  the  air  out  of 
the  hollow  needle.  In  order  to  avoid  a  possible  breaking  of  the 
point  of  the  needle,  the  bevelled  part  of  it  is  made  very  short.  To 
the  needle  is  screwed  a  common  hypodermic  syringe  containing  a 
sterile,  freshly  prepared  two  per  cent,  solution  of  hydrochlorate  of 
cocaine.  Since  cocaine  is  decomposed  by  heat,  the  salt  should  be  dis- 
solved in  sterile  water  and  only  boiled  for  one  minute.  Of  this  solu- 
tion from  ten  to  fifteen  minims  are  injected,  containing  from  one-fifth 
to  one-fourth  grain  of  the  salt.  Fully  a  minute  should  be  devoted  to 
the  injection,  and  the  syringe  should  not  be  removed  from  the  needle 
for  at  least  two  minutes  after  injecting. 

Occasionally  there  is  a  preliminary  hypersesthesia,  but  this  is  tran- 
sient, and  in  from  two  to  fifteen  minutes  anaesthesia  is  generally  com- 
plete. If  at  the  end  of  half  an  hour  the  desired  result  is  not  obtained, 
or  if  after  complete  anaesthesia  the  sensation  of  pain  returns,  the 
injection  may  be  repeated.  In  this  way  three-fourths  of  a  grain  has 
been  injected  within  an  hour.  The  anaesthesia  extends  always  from 
the  umbilicus  downward  to  the  tips  of  the  toes,  and  sometimes  up  to 
the  neck  or  even  the  vertex.  It  lasts  from  thirty  minutes  to  several 
hours.  The  immediate  result  and  the  sequels  are  not  pleasant.  Com- 
plaints of  burning  pains  in  legs  and  feet  are  common.  Frequently 
there  are  nausea,  vomiting,  severe  headache,  profuse  perspiration,  and 
chilly  sensations.  The  pulse-rate  increases  and  the  temperature  may 
rise  to  103°  F.  In  some  cases  rigidity  of  the  muscles  of  the  back  fol- 
lowed the  injection  and  lasted  for  a  week.  Alarming  respiratory 
failure,  staggering  gait,  tingling  and  numbness,  great  spinal  pain  on  the 
day  following  the  operation,  and  vertigo  have  also  been  observed; 
likewise  a  case  of  cyanosis,  pulselessness,  and  loss  of  consciousness. 
1  Marx,  Medical  News,  August  25,  1900  ;  Medical  Record,  October  6,  1900. 


206  NORMAL    LABOR. 

In  some  cases  no  angesthesia  has  been  obtained  or  it  has  been 
more  or  less  imperfect.  A  disagreeable  feature  is  the  tendency  to 
involuntary  defecation  and  urination  sometimes  observed.  In  several 
cases  the  medullary  cocainization  has  resulted  in  death. 

In  multiparae  the  injection  should  be  made  when  the  os  is  three- 
fourths  dilated,  in  primiparce  when  it  is  fully  dilated.  By  repetition 
of  the  injection  during  eight  hours  patients  have  been  carried  prac- 
tically without  pain  through  their  labor.  Explorations,  versions, 
extractions,  and  placental  removals  were  readily  done,  not  with  quite 
as  great  ease  as  under  chloroform,  but  with  greater  facility  than  in  a 
non-anassthetized  woman. 

In  order  to  avoid  some  of  the  unpleasant  or  dangerous  effects, 
especially  vomiting,  headache,  and  heart-failure,  it  has  been  recom- 
mended to  give  twenty  grams  of  bromide  of  potassium  a  couple  of 
hours  before  and  one-tenth  of  a  grain  of  strychnine  hypodermically 
immediately  before  making  the  intraspinal  injection. 

The  author  has  not  used  medullary  cocainization,  and  does  not 
intend  to  do  so.  In  his  opinion  this  new  method  of  inducing  analge- 
sia has  a  very  limited  field  in  general  surgery, — namely,  in  patients  in 
whom  on  account  of  combined  heart  and  kidney  disease  both  chloro- 
form and  ether  seem  undesirable.  Even  those  who  are  in  favor  of 
the  method  do  not  recommend  it  for  laparotomy.  It  does  not  give 
the  needed  laxity  of  the  abdominal  wall,  and  the  peritoneum  has 
proved  sensitive  when  there  was  complete  ansesthesia  of  the  lower 
extremities. 

In  obstetrics  I  do  not  think  there  is  any  call  for  this  innovation. 
Cocaine  is  at  best  a  treacherous  drug.  The  individual  susceptibility 
to  it  varies  enormously,  and  the  effect  is  also  different  in  different 
parts  of  the  body.  The  nearer  to  the  brain  the  application  is  made 
the  greater  is  the  danger ;  and  if  in  this  case  the  puncture  is  made 
far  away  from  the  encephalon,  on  the  other  hand  the  injected  fluid 
mixes  with  the  cerebrospinal  fluid,  which  directly  bathes  the  whole 
central  ner\^ous  system.  It  is  impossible  to  know  exactly  where  the 
end  of  the  needle  is,  and  we  may  therefore  unawares  inject  the  fluid 
either  into  a  nerve  of  the  cauda  equina  or  into  one  of  the  large  veins 
that  surround  the  spinal  marrow.  Whether  the  injury  to  a  nerve 
would  have  any  bad  effect  is  not  known,  but  the  injection  into  a  vein 
is  not  unlikely  to  be  dangerous,  and  may  account  for  some  of  the 
numerous  undesirable  threatening  or  fatal  effects  obser\'ed  in  some 
cases. 

While  the  drug  itself  and  the  place  of  its  application  are  a  source 
of  danger,  there  is  also  considerable  clanger  of  s.epsis.  Do  what  we 
like,  the  skin  cannot  be  disinfected.  In  the  deeper  parts  of  the 
cutaneous  glands  the  microbes  find  a  lurking-place  from  which  no 


CONDUCT    OF    NORMAL    LABOR.  207 

amount  of  disinfectants  applied  to  the  epidermis  can  dislodge  them. 
In  passing  through  the  skin  the  needle  may  therefore  carry  them  into 
the  spinal  canal,  where  they  still  more  escape  our  vigilance  and  may 
begin  their  deleterious  work.  I  am  fully  aware  that  this  would  also 
apply  to  hypodermic  injections,  of  which  hundreds  are  given  without 
causing  inflammation.  But  occasionally  we  see  even  such  an  injec- 
tion followed  by  the  formation  of  an  abscess,  and  if  carried  right  into 
the  cerebrospinal  fluid  or  into  the  lumen  of  a  spinal  vein,  the  effect 
would  probably  be  much  more  serious.  The  danger  of  sepsis  is 
therefore  immanent  in  this  method. 

Even  if  the  patient  comes  safely  through  the  operation,  certain 
most  important  after-effects,  such  as  vomiting,  severe  headache,  etc., 
await  her  in  nearly  all  cases.  The  puncture  itself  made  with  a  needle 
that  must  have  solidity  enough  not  to  break,  especially  a  repeated 
puncture,  must  cause  an  amount  of  pain  which  cannot  be  disregarded 
any  more  than  the  patient's  fear  of  what  she  is  going  to  suffer  in  her 
perfectly  conscious  condition. 

Looked  at  from  the  special  stand-point  of  the  obstetrician,  the 
method  seems  to  have  serious  drawbacks.  All  sensation  of  pain 
being  absent,  the  distention  of  the  perineum  cannot  call  into  opera- 
tion the  normal  reflex  contraction  of  the  abdominal  muscles,  as  a  result 
of  which  the  second  stage  of  labor  is  unduly  prolonged  or  tempts 
the  accoucheur  to  abbreviate  it  by  operative  interference.  Thus,  in  a 
report  of  twenty-two  cases  of  normal  lalDor  treated  with  medullary 
cocainization,  I  find  that  delivery  was  accomplished  seven  times  by 
forceps  and  three  times  by  manual  extraction  or  version.  If  it  is 
necessary  to  deliver  artificially  in  nearly  half  the  whole  number  of 
cases,  that  alone  would  be  enough  to  condemn  the  procedure. 

Finally,  it  seems  to  me  utterly  superfluous  and  uncalled  for  to 
subject  the  parturient  woman  to  the  multifarious  discomforts  and  great 
dangers  of  medullary  cocainization  when  in  chloroform  we  have  an 
absolutely  ideal  anaesthetic  for  the  alleviation  or  abolition  of  the 
throes  of  labor.  Whatever  may  be  thought  of  the  safety  or  danger 
of  the  use  of  this  drug  in  surgical  operations,  in  labor  cases  there 
has  never,  to  the  writers  knowledge,  been  reported  a  case  of  death 
attributable  to  its  administration.  The  reason  of  this  wonderful  im- 
munity is  probably  to  be  found  in  the  condition  of  the  heart,  which 
by  the  exertions  incident  to  labor  is  strengthened  to  its  utmost  vigor. 
The  accoucheur  can  vary  the  amount  given  and  the  intervals  between 
the  applications  of  the  mask  to  a  nicety,  and  at  any  moment  discon- 
tinue the  anaesthetic.  He  can  allow  so  much  pain  to  be  felt  as  he 
thinks  necessary  to  call  into  action  reflex  contractions  and  to  avoid 
post-partum  hemorrhage.  He  can,  so  to  say,  merely  take  off  the 
edge  of  the  pain,  or  he  can  produce  so  deep  an  anaesthesia  that  the 


208  NORMAL   LABOR. 

greatest  operations  may  be  performed  without  the  knowledge  of  the 
patient.  There  are  no  unpleasant  sensations  whatsoever  connected 
with  the  use  of  chloroform  either  during  or  after  its  administration. 
It  affords  simply  unspeakable  relief  to  the  poor  sufferer.  If  used  in 
normal  labor  it  is  not  even  followed  by  vomiting  or  nausea,  as  is 
sometimes  the  case  after  operations.  The  moment  the  child  is  born, 
the  mother  is  as  free  from  pain  and  discomfort  as  when  no  anaesthetic 
has  been  given. 

Hypnotism. — Hypnotists  claim  that,  at  least  in  some  women,  they 
can  produce  such  a  deep  sleep  that  the  patient  is  not  awakened  by 
the  pains  of  labor,  and  that  after  awakening  she  has  no  recollection 
whatever  of  what  has  taken  place.  I  was  once  invited  by  a  very  skilful 
and  experienced  hypnotist  to  witness  the  effect  of  hypnotism  in  a 
confinement  case.  On  other  occasions  I  had  seen  this  man  produce 
all  sorts  of  hallucinations,  take  away  pain,  and  even  make  the  pulse 
beat  simultaneously  with  different  frequency  at  the  two  wrists  of  the 
same  person,  and  in  this  case  the  patient  was  quite  accustomed  to 
being  anaesthetized.  It  was  her  sixth  confinement,  and  the  child  was 
small,  weighing  between  five  and  six  pounds.  But  in  spite  of  all 
these  favorable  circumstances,  the  exhibition  was  almost  a  complete 
failure.  The  patient  complained  of  headache.  The  doctor  stroked 
her  head,  and  it  passed  off  immediately.  But  labor-pains  made  her 
groan  and  contract  her  face  just  as  much  as  any  other  woman,  and 
on  being  questioned  she  said  she  had  bad  pain.  When  the  head 
began  to  distend  the  vulva  and  when  it  passed,  she  cried  out  wildly 
and  declared  she  had  never  suffered  so  much.  Of  course,  it  is  far 
from  me,  on  account  of  this  single  case,  to  reject  what  has  been  stated 
by  several  hypnotists  here  and  in  Europe  ;  but  if  we  take  into  con- 
sideration that  only  few  physicians  can  produce  the  hypnotic  con- 
dition in  the  patient,  that,  as  a  rule,  the  hypnotist  has  gradually  in 
repeated  sittings  to  gain  power  over  the  patient,  and  that  many  think 
that  hypnotism  weakens  the  nervous  system,  it  is  not  hkely  that 
suggestion  will  replace  chloroform  to  any  extent. 


CHAPTER    VIII. 

CARE    OF   THE   NEW-BORN    CHILD. 

When  the  accoucheur  is  through  with  the  mother,  he  should 
return  to  the  child,  which  had  been  temporarily  placed,  properly 
wrapped  up,  at  the  foot  of  the  bed  or  in  some  other  safe  and  suitable 
place.  He  should  inspect  the  navel-cord  and  satisfy  himself  that 
there  is  no  bleeding.  If  there  is,  he  reopens  the  ligature  and 
tightens  it. 


CARE   OF   THE   NEW-BORN    CHILD.  209 

Next,  the  eyes  should  receive  attention.  In  lying-in  hospitals 
they  should  be  washed  outside  with  a  saturated  solution  of  boric  acid, 
and,  spreading  the  lids  open  between  the  left  thumb  and  index-finger, 
one  drop  of  a  two  per  cent,  solution  of  nitrate  of  silver  should  be 
allowed  to  fall  on  the  centre  of  the  cornea  from  a  dropper,  or  prefer- 
ably from  a  solid  glass  rod,  since  the  latter  holds  only  one  drop, 
while  by  a  careless  use  of  the  dropper  sometimes  several  drops  have 
been  squirted  into  the  eye.  This  method  was  invented  by  Professor 
Carl  F.  S.  Crede,  of  Leipsic,  and  shortly  after,  on  the  14th  of  October, 
1882,  introduced  by  the  author  in  America.^ 

The  object  of  this  treatment,  which  may  seem  unnecessarily 
harsh,  is  to  preserve  the  infant  from  acquiring  ophthalmia  neona- 
torum by  infection  during  its  passage  through  the  parturient  canal  of 
a  woman  suffering  from  gonorrhoea.  Before  the  preventive  treatment 
was  generally  adopted,  this  purulent  ophthalmia  was  a  very  common 
disease  of  the  eyes  of  new-born  children  in  lying-m  hospitals,  and, 
according  to  large  statistics,  from  one-third  to  two-thirds  of  those 
affected  with  blindness  lost  their  sight  from  this  cause.  When  once 
the  disease  is  developed,  such  care  is  needed  to  prevent  it  from  end- 
ing in  blindness  that  at  least  two  nurses  are  required  to  carry  out  the. 
necessary  treatment,  consisting  in  frequent  irrigation  of  the  eyes  with 
saturated  solution  of  boric  acid  and  still  more  frequent  applications  of 
ice  compresses  to  the  lids.  If  now  we  take  into  consideration  how 
often  the  gonococcus  is  found  in  the  vaginal  secretions  of  the  women 
delivered  in  lying-in  hospitals,  and  that  the  instillation  of  silver  nitrate 
is  an  almost  mfallible  preventive  and,  as  a  rule,  is  quite  safe,  there 
cannot  be  any  doubt  about  the  wisdom  of  using  this  prophylaxis  as 
routine  treatment  in  such  institutions.  In  most  cases  there  is  no 
reaction  w^hatsoever.  In  some  I  observed  a  slight  serous  discharge 
from  the  conjunctiva,  w^hich  disappeared  in  a  few  days  without  any 
treatment.  I  do  not  use  this  method  in  private  practice  except  when 
I  know  that  the  mother  or  the  father  of  the  child  recently  has  had  a 
gonorrhoea,  or  in  cases  in  which  the  mother  during  pregnancy  has 
been  suffering  from  a  purulent  discharge  from  the  vagina.  If  I  use 
this  preventive,  I  do  it  without  calling  any  attention  to  it,  or  even 
without  the  knowledge  of  the  parents.  Under  such  circumstances  the 
danger  of  the  child  falling  a  victim  to  purulent  ophthalmia  is  so  great 
that  remote  possibilities  of  trouble  arising  from  the  instillation  ought 
not  to  carry  weight. 

Of  late  protargol  in  a  10  per  cent,  solution  has  been  substituted 
for  the  nitrate  of  silver.  It  is  said  to  be  as  effective  and  much  less 
irritating.     Under  ordinary  circumstances  I  take  it  to  be  sufficient  to 

'  Henry  J.  Garrigues,  Prevention  of  Ophthalmia  Neonatorum,  Amor.  Jour. 
Med.  Sci.,  October,  1884. 

14 


210  NORMAL   LABOR. 

wash  the  eyes  of  the  child  with  plain  cold  water  or  saturated  solution 
of  boric  acid  and  a  fine  pledget,  be  it  sterilized  gauze  or  absorbent 
cotton,  or  a  piece  of  a  fine  pocket  handkerchief. 

When  the  eyes  and  the  mouth  have  been  cleaned,  but  not  before, 
the  baby  should  have  its  bath.  Officious  by-standers  are  very  apt  .o 
offer  their  services  in  washing  it  immediately  after  its  birth,  and  even 
to  complain  that  it  is  being  neglected.  This  is  without  foundation. 
The  child  does  not  suffer  in  any  way  when  it  is  properly  wrapped  up 
and  safely  deposited,  whereas,  the  third  period  of  labor  being  by  far 
the  most  dangerous  for  the  mother,  full  attention  should  be  concen- 
trated upon  her,  and  the  child  should  wait  till  everything  has  been 
done  for  the  mother. 

Whenever  possible,  the  child  should  be  bathed  in  a  baby  wash- 
tub.  Small  children  hate  as  much  to  be  washed  as  they  delight  in 
mo^dng  their  little  limbs  without  restraint  in  the  lukewarm  water  of 
the  bath.  As  a  rule,  the  accoucheur  leaves  the  cleaning  of  the  child 
to  the  nurse,  but  he  should  certamly  in  the  begmning  of  his  career 
practise  this  part  of  the  duties  of  the  lying-in  room  himself,  and  be 
perfectly  familiar  with  all  its  details,  if  for  no  other  reason,  in  order 
to  be  al^le  to  give  intelligent  instructions  and  supervise  the  work  of 
the  nurse.  The  water  should  be  slightly  below  the  temperature  of 
the  blood, — about  98°  F.  If  no  thermometer  is  available,  the  nurse 
may  use  her  elbow — not  her  hand,  which  is  more  accustomed  to 
high  temperature — for  testing  that  of  the  water.  White  Castile  soap 
should  be  used,  as  it  contams  neither  coloring  matter  nor  perfumes 
nor  acrid  substances ;  but  soap  does  not  easily  remove  the  vernix 
caseosa.  In  places  where  much  of  this  substance  has  accumulated, 
especially  the  armpits  and  the  groins,  the  child  should  first  be 
anointed  with  sweet  oil.  In  washing  the  head,  care  should  be  taken 
that  the  soap  does  not  trickle  down  into  the  eyes.  The  child  should 
all  the  time  be  sustamed  by  placing  the  left  hand  under  the  back  of 
the  head,  so  as  to  hold  the  face  above  the  surface  of  the  water. 
When  the  child  is  clean,  it  is  lifted  out  of  the  bath  and  dried  with  a 
warm,  soft  towel  or  cotton  cloth,  and  dressed. 

In  private  practice  all  I  personally  do  for  the  navel-cord  after 
having  tied  it  is  to  put  a  piece  of  absorbent  cotton  over  it,  which 
comes  off  in  the  next  bath,  and  I  have  never  had  a  case  of  inflamma- 
tion arising  from  the  navel ;  but  since  in  cutting  the  cord  we  leave 
a  wound,  and  since,  as  we  shall  see  later,  this  is  a  chief  source  of 
disease  in  the  new-born  child,  it  is  rational  to  dress  it  antiseptically; 
In  so  doing  we  should  avoid  fatty  substances,  and  use  only  dry  pow- 
ders wliich  contribute  to  the  mummihcation  of  the  stump  ;  for  instance, 
one  part  of  salicylic  acid  mixed  with  five  parts  of  starch,  or  equal  parts 
of  subnitrate  of  bismuth,  tannin,  and  lycopodium,  or  pure  boric  acid. 


MIDWIVES.  211 

Some  have  of  late  closed  the  wound  in  the  cord  with  a  running 
catgut  suture,  uniting  the  edges  of  the  amniotic  sheath.  The  cotton 
is  kept  in  place  by  surrounding  the  middle  of  the  abdomen  of  the 
child  Avith  a  piece  of  flannel  two  feet  long  and  about  six  inches  wide. 
It  goes  once  and  a  half  times  round  the  body,  and  is  fastened  in  front 
Avith  safety-pins.  Next,  a  little  woollen  undervest  is  slipped  over  the 
chest  and  abdomen  and  upper  part  of  the  arms.  Then  the  buttocks 
and  groins  are  covered  with  a  diaper, — that  is,  a  square  piece  of  mus- 
lin or  linen  folded  so  as  to  form  a  triangle,  the  base  of  which  lies  on 
the  cliild's  back,  while  the  three  ends  come  together  in  front  and  are 
fastened  with  a  safety-pin.  Then  a  long  flannel  petticoat  or  a  square 
piece  of  flannel  going  half  a  yard  beyond  the  feet  is  fastened  around 
the  waist  and  folded  up  in  front  of  the  legs.  The  feet  are  covered 
with  woollen  socks.  Outside  of  the  flannel  petticoat  is  put  one  of 
Avhite  cotton,  and  finally  a  Avhite  dress,  Avhen  the  baby  is  ready  to  be 
presented  to  its  mother. 


CHAPTER    IX. 
MIDWIVES. 


In  foreign  countries  and  in  all  the  States  of  the  Union  except 
Nebraska,  a  large  number  of  confinements  are  in  the  hands  of  mid- 
wives.  In  the  city  of  Ncav  York  more  than  one-half  of  the  parturient 
women  are  attended  by  this  class  of  helpers.  Most  of  them  are  Ger- 
mans, Scandinavians,  or  Italians  by  birth,  and  are  employed  chiefly 
by  their  own  countrywomen,  the  American  and  the  Irish  Avomen 
being  too  intelligent  and-  Avell  informed  to  avail  themselves  of  these 
ignorant  and  uncleanly  beings.  Originally  any  Avoman  who  had  her- 
self borne  a  child  assisted  her  friends  in  their  labors,  but  in  the 
course  of  time  special  authorized  guilds  of  midAvives  Avere  formed  Avho 
alone  possessed  the  right  to  practise  the  art,  and  who  called  in  a 
physician  only  Avhen  they  found  themselves  incapable  of  completing 
a  delivery.  It  Avas  first  in  the  beginning  of  the  seventeenth  century 
that  in  Paris  doctors  commenced  to  assume  the  direction  of  normal 
labor  cases.  In  the  year  1600  Charles  Guillemeau  and  Honore  began 
to  be  in  great  request  by  most  ladies  of  quality.  In  England  physi- 
cians Avere  not  employed  in  normal  labor  cases  before  the  end  of  the 
eighteenth  century,  and  at  first  the  so-called  men-midwives  met  Avith 
great  opposition.  In  Germany  the  old  system  obtained  much  longer 
and  to  a  great  extent  still  exists,  but  it  has  become  quite  usual  for 
well-to-do  Avomen  to  employ  physicians  as  accoucheurs  instead  of 
midwives.  In  Denmark  also  some  years  ago  physicians  began  to 
attend  normal  labor  cases.     The  reason  of  this  gradual  domination  of 


212  NORMAL   LABOR. 

the  field  of  midwifery  by  physicians  is  that  the  superiority  of  the  new 
system  over  the  old  at  once  becomes  so  manifest  wherever  it  is  tried 
that  women  conquer  their  natural  aversion  to  the  exposure  of  their 
persons  to  the  sight  and  touch  of  the  male  practitioner  of  midwifery. 

Compared  w4th  men,  women  have  done  very  little  for  the  advance- 
ment of  the  obstetric  art.  Of  tlie  hundreds  of  thousands  of  midwives 
who  have  plied  their  art  only  four  have  given  expression  to  their 
experience  in  printed  books,  three  in  France  and  one  in  Germany. 
The  oldest  work  of  this  kind  is  that  of  Louyse  Bourgeois  (1609), 
but  that  of  Guillemeau  bears  the  same  date.  Justine  Siegemundin 
published  her  "  Konigliche  und  Churbrandenburgsche  Wehemutter"  in 
1690.  Mme.  Boivin  dedicated  her  work  in  1811  to  Mme.  Lachapelle, 
whose  pupil  she  styles  herself.  In  1821  the  latter  published  the  first 
volume  of  her  treatise  on  "The  Art  of  Accouchement,"  the  last  two 
volumes  of  which  were  edited  by  her  nephew,  Antoine  Duges,  pro- 
fessor of  obstetrics  at  Montpellier.  Great  as  the  experience  and  dex- 
terity of  these  women  may  have  been,  the  science  and  art  of  obstetrics 
is  not  a  structure  of  their  rearing,  but  of  physicians  from  Hippocrates 
to  the  present  time. 

Obstetric  work  presents  certain  peculiarities  Avhich  make  it  pre- 
eminently objectionable  to  tolerate  its  performance  by  half-taught  or 
totally  ignorant  persons.  Without  a  careful  examination,  of  which 
even  the  best  midwife,  owing  to  her  lack  of  scientific  knowledge  and 
training,  is  entirely  incapable,  it  is  in  most  cases  impossible  to  foretell 
whether  a  labor  case  will  take  a  normal  course  or  present  difficulties 
that  can  be  met  only  by  all  the  resources  of  the  most  advanced  art, 
and,  as  an  old  French  accoucheur  said  of  labor,  "If  it  is  easy,  it  is 
nothing;  but  if  it  is  difficult,  it  is  the  most  difficult  of  all  things.''' 
While  in  other  branches  of  the  heahng  art  every  case  concerns  the 
well-being  or  restoration  to  health  of  one  human  being,  in  obstetrics 
every  case  involves  the  fate  of  at  least  two  individuals.  Besides  the 
specific  services  rendered  by  the  obstetrician,  at  least  three  other 
specialties — internal  medicine,  surgery,  and  paediatrics — are  more  or 
less  constantly  involved.  In  no  other  department  does  prevention  of 
evil  play  a  similar  role.  Very  often  the  demand  for  immediate  action 
is  imperative,  so  that  no  time  is  left  for  examining  books  or  consulting 
men  of  larger  experience. 

As  we  shall  see  further  on,  in  no  branch  of  the  medical  art  has 
the  inauguration  of  antiseptic  measures  wrought  greater  reduction  in 
mortality.  In  an  apparently  simple  case  the  greatest  operations  may 
become  necessary,  and  the  choice  of  methods  and  the  results  depend, 
first  of  all,  on  the  aseptic  condition  of  the  genital  tract.  Unfortu- 
nately, many  physicians  are  far  from  doing  their  duty  in  this  respect ; 
but  most  young  men  are  now  so  well  informed  in  regard  to  the 


MID  WIVES.  213 

advantages  to  be  obtained  by  following  the  rules  of  antisepsis  and 
asepsis  in  general  surgery,  in  the  surgical  specialties,  and  even  in 
internal  medicine,  that  they  are  willing  to  take  a  reasonable  amount 
of  trouble  in  order  to  secure  clean  midwifery,  whereas  mid  wives  do 
not  understand  the  first  principles  of  surgical  cleanliness,  and  are  as 
unwilling  as  they  are  incompetent  to  apply  them. 

They  are  also  incapable  of  foreseeing  complications,  and  by  the 
time  they  realize  that  there  is  something  wrong  the  evil  may  have 
become  irremediable.  Both  mortality  and  morbidity  are  much  greater 
in  their  practice  than  in  that  of  physicians.  The  mortality  in  childbed 
in  private  practice  in  New  York  City  is  twice  as  large  as  that  in  the 
lying-in  institutions.  The  pure,  the  healthy,  the  rich  are  apt  to  lose 
their  lives  by  giving  birth  to  a  child  in  their  luxurious  homes,  while 
the  dissolute,  those  whose  constitutions  are  undermined  by  disease, 
overwork,  and  care,  those  who  are  struggling  with  poverty  for  mere 
existence,  are  nearly  sure  of  leaving  the  hospital  in  a  better  condition 
than  they  entered  it. 

The  writer  has  in  practice  in  a  large  dispensary  which  is  used 
chiefly  by  foreigners,  who  almost  exclusively  employ  midwives  in 
their  confinements,  ample  opportunity  of  seeing  the  bad  effect  of  the 
poor  assistance  they  receive  in  childbirth.  A  simple  tear  of  the  peri- 
neum, which  the  conscientious  physician  effectually  repairs  with  a  few 
stitches,  is  left  to  heal  as  best  it  can,  and  becomes  the  source  of 
suffering  and  the  cause  of  mechanical  changes  that  later  call  for  serious 
operations. 

Children  suffer  under  bad  midwifery  still  more  than  their  mothers. 
Not  only  is  the  mortality  among  them  great,  but  that  terrible  scourge 
ophthalmia  neonatorum,  ending  in  life-long  blindness,  is  much  more 
common  among  the  patients  of  midwives,  who  do  not  even  surmise 
the  importance  of  the  case,  and  often  recommend  the  use  of  imagi- 
nary remedies  for  what  is  supposed  to  be  a  mere  cold,  than  among 
those  of  doctors,  who  have  been  taught  the  danger,  and  who  either 
prevent  the  disease  or  cure  it  in  its  incipient  stage,  or  turn  the  little 
patient  over  to  the  care  of  the  ophthalmologist. 

Even  in  European  countries,  where  the  pupil  midwives  are  in- 
structed in  universities  by  the  same  professors  who  teach  the  students 
of  medicine,  where  they  have  a  course  extending  through  years,  and 
where  they,  after  having  entered  on  practice,  are  under  strict  govern- 
ment control, — even  there  constant  complaints  are  being  uttered  in 
the  medical  press  in  regard  to  the  inefficiency  and  shortcomings  of 
midwives. 

Midwives  do  harm  not  only  through  their  lack  of  obstetric  knowl- 
edge, their  neglect  of  antiseptic  precautions,  and  their  tendency  to 
conceal  undesirable  features,  but  most  of  them  are  the  most  iiiveter- 


214  NORMAL    LABOR. 

ate  quacks.  First  of  all  they  treat  disturbances  occurring  during  the 
puerpery,  later  gyngecological  diseases,  then  diseases  of  children,  and 
finally  they  are  consulted  in  regard  to  almost  everything.  They  never 
acknowledge  their  ignorance,  and  are  always  ready  to  give  advice. 
They  administer  potent  drugs,  such  as  ergot  and  opium.  Their  thinly 
veiled  advertisements  in  the  newspapers  show  them  to  be  willing 
abortionists ;  and,  since  they  have  the  right  to  give  certificates  of  still- 
birth, who  knows  whether  or  not  an  infant's  death  is  due  to  natural 
causes  or  to  criminal  manipulations  ? 

Although  an  evil,  midwives  are,  however,  in  most  countries  a 
necessity,  in  view  of  the  fact  that  physicians  would  not  find  time  to  do 
the  work  needed ;  but  this  does  not  apply  to  America,  where  there  is 
a  superabundance  of  medical  practitioners.  According  to  the  census 
of  1890,^  the  population  of  the  United  States  on  the  first  day  of  June 
of  that  year  was  62,979,766,  or,  leaving  out  Alaska  and  the  Indian 
Territory,  62,622,250.  Of  these  30,554,370  were  females,  but  only 
15,742,636  were  in  the  childbearing  age, — from  fifteen  to  forty-nine 
years.  At  the  same  time  there  were  104,805  physicians  and  sur- 
geons, which  gives  one  physician  for  every  one  hundred  and  fifty 
women  of  a  childbearing  age.  Now,  we  may,  even  by  liberal  calcu- 
lation, estimate  that  on  an  average  women  in  America  give  birth  to 
only  four  children  in  all.  Consequently  the  number  of  women  in  the 
childbearing  age  (thirty-five  years)  must  be  divided  by  about  nine  in 
order  to  find  the  average  number  of  births  per  annum,  which  gives 
less  than  seventeeyi  confinements  per  year  for  each  j^hysician  in  the  United 
States. 

In  the  State  of  New  York  the  total  population  was  5,997,853,  of 
which  3,020,960  were  females.  Taking  the  proportion  for  the  United 
States,  this  leaves  1,155,190  women  of  childbearing  age.  Now, 
there  were  11,139  physicians  and  surgeons,  or  one  physician  for 
every  one  hundred  and  thirty-nine  women  of  childbearing  age,  or  an 
average  of  a  little  more  than  fifteen  confinements  per  annum  for  each 
physician  in  the  State  of  New  York. 

In  the  city  of  New  York,  as  it  was  before  it  was  merged  with  the 
counties  of  Kings,  Queens,  and  Richmond  into  Greater  New  York, 
the  proportion  between  physicians  and  labor  cases  became  still 
smaller.  At  the  census  of  1890  the  total  population  of  the  city,  cor- 
responding to  the  boroughs  of  Manhattan  and  Bronx,  was  1,515,301. 
Of  these  767,722  were  females,  and  by  computation  it  is  found  that 
of  these  395,556  were  of  a  childbearing  age.  The  number  of  male 
physicians  was  3266  ;  that  of  the  female  is  not  specified  in  the 
census,  but  the  Medical  Directory  for  1897  shows  that  in  that  year 

^  At  the  time  of  going  to  press  the  published  reports  of  tlie  census  of  1900 
have  not  yet  reached  the  subject  of  the  business  of  the  inhabitants. 


MIDWIVES.  215 

there  were  145,  which  gives  a  total  of  3411  physicians  and  surgeons. 
Consecjuently  there  was  one  physician  for  every  one  hundred  and 
eighteen  women  in  the  childbearing  age,  or  an  average  of  thirteen  con- 
finements yearly  for  each  physician  practising  in  the  city  of  New  York. 
Nobody  will,  therefore,  deny  that  physicians  can  easily  attend  to  all 
labor  cases. 

Analogies  cannot  be  drawn  from  European  countries.  New  York 
has  proportionately  to  the  population  nearly  twice  as  many  physicians 
as  London,  and  the  United  States  nearly  three  times  as  many  as 
Great  Britain.  On  the  continent  of  Europe  there  are  still  fewer 
doctors,  varying  from  one  in  two  thousand  to  one  in  six  thousand 
inhabitants. 

Even  those  who  object  to  male  accoucheurs  can  to  a  great  extent 
be  conciliated,  as  nowhere  is  there  such  a  number  of  female  physi- 
cians. According  to  the  above  statistics,  there  were  in  1890  in  the 
United  States  4557  and  in  the  State  of  New  York  693. 

Another  objection  to  the  exclusive  employment  of  physicians  as 
accoucheurs  has  been  raised  on  financial  grounds ;  but  with  the  large 
number  of  physicians  who  have  plenty  of  spare  time,  their  services 
can  be  obtained  for  the  same  price  as  those  paid  to  a  midwife.  If 
the  patient  is  too  poor  to  pay  even  that  modest  sum,  she  can  in  the 
city  of  New  York  with  the  greatest  facility  obtain  gratuitous  help  in 
her  confinement,  either  in  a  hospital  or  in  her  own  home,  as  she 
prefers.  The  explanation  of  this  curious  fact  is  that  of  all  medical 
charities  none  is  so  overdone  as  this.  I  was  formerly  at  the  head  of 
the  department  of  a  dispensary  which  sends  an  experienced  accoucheur 
to  the  patient's  home  and  furnishes  gratuitously  all  necessary  mate- 
rials, drugs,  and  medicines,  and  still  only  an  insignificant  number  of 
women  avail  themselves  of  this  privilege,  freely  advertised  by  means 
of  a  placard  placed  conspicuously  in  the  windows  of  the  said  dispen- 
sary. The  number  of  confinements  in  the  official  Maternity  Hospital 
of  the  City  of  New  York  has  dwindled  down  to  little  above  two  hun- 
dred a  year ;  and  how  could  it  be  otherwise,  when  one  commercial 
Croesus  after  the  other  constructs  palatial  lying-in  hospitals,  when 
religious  orders  and  lay  societies  vie  with  one  another  who  can  attract 
most  patients,  and  when  medical  schools  use  every  effort  to  obtain 
material  for  the  instruction  of  their  students  ? 

The  institution  of  mid  wives  is  a  remnant  of  barbaric  times,  a  blot 
on  our  civilization  which  ought  to  be  wiped  out  as  soon  as  possible. 
As  America  has  led  the  world  in  establishing  colleges  for  the  educa- 
tion of  women  physicians,  let  it  also  form  the  vanguard  in  a  war  of 
extermination  against  those  pestiferous  remnants  of  preantiseptic  days, 
midwives  and  schools  of  midwifery.  The  beginning  has  already  been 
made  in  the   State   of  Nebraska,  where   midwifery,  like  any  other 


216  NORMAL   LABOR. 

branch  of  medical  practice,  is  exclusively  in  the  hands  of  doctors  of 
medicine,  be  they  men  or  women.  This  law  has  been  in  force  there 
for  a  number  of  years,  and  works  well.  To  recognize  mid  wives  and 
give  them  a  legal  standing  would  be  to  go  back  to  the  times  when 
stone-cutters,  oculists,  bonesetters,  herniotomists,  and  other  so-called 
specialists  plied  their  trade  under  the  eyes  of  the  law. 

On  January  27,  1898,  the  Section  on  Obstetrics  and  Gynaecology 
of  the  New  York  Academy  of  Medicine  passed  the  following  resolu- 
tions : 

"  Whereas,  Midwifery,  or  obstetrics,  is  an  important  branch  of  medical  science 
and  art ; 

' '  Whereas,  Midwives  are  not  recognized  by  the  State  ; 

"  Whereas,  Section  153  of  the  Laws  of  New  York,  1893,  Chapter  661, 
amended  in  1895,  prescribes  penalties  for  any  person  who,  without  being  then 
lawfully  authorized  to  practise  medicine  within  this  State  and  so  registered  accord- 
ing to  the  law,  .  .  .  shall  assume  or  advertise  any  title  which  shall  show,  or 
tend  to  show,  that  the  person  assuming  or  advertising  the  same  is  a  practitioner 
of  any  of  the  branches  of  medicine  ; 

"  Whereas,  Midwives  by  their  gross  ignorance  and  lack  of  cleanliness  do  great 
harm  to  parturient  and  lying-in  women,  and  assume  to  administer  potent  drugs 
to  them  without  the  advice  of  a  physician,  and  often  treat  sick  women  and  chil- 
dren, and  frequently  are  guilty  of  causing  abortions  : 

' '  Resolved,  That  the  Section  on  Obstetrics  and  Gynaecology  strongly  recom- 
mends the  taking  of  immediate  steps  to  secure  the  passage  of  a  law  providing  for 
the  supervision  of  all  persons,  not  legally  qualified  physicians,  now  engaged  in 
practising  midwifery,  and  debarring  from  such  practice  all  persons  not  proven  to 
be  competent  and  qualified  ;  and  also  containing  such  provisions  as,  without  con- 
flicting with  existing  rights,  shall  tend  to  confine  the  practice  of  midwifery  to 
qualified  medical  practitioners. ' '  ^ 


CHAPTER    X. 
LYING-IN   INSTITUTIONS. 

Long  before  having  any  direct  influence  on  any  hospital  destined 
for  the  reception  and  care  of  pregnant,  parturient,  and  puerperal 
women,  the  writer  made  himself  the  champion  of  these  institutions, 
the  very  existence  of  which  at  that  time  was  seriously  menaced.^  He 
treated  this  question  at  some  length  in  a  paper  by  which  he  sought 
and  obtained  the  honor  of  fellowship  in  the  American  Gynaecological 
Society. 

Prompted  by  Leon  Lefort,  of  Paris,  the  International  Medical 
Congress,  assembled  at  Brussels  in  1876,  had  adopted  resolutions 
demanding  the  abolishment  of  large  lying-in  hospitals,  and  recom- 

^  Garrigues,  "Midwives,"  The  Medical  News,  February  19,  1898. 
^  Garrigues,  "On  Lying-in  Institutions,  especially  those  in  New  York,"  Trans. 
Amer.  Gyn.  Soc,  1877,  vol.  ii.  pp.  592-645. 


LYING-IN    INSTITUTIONS.  217 

mending  that  women  be  confined  in  the  houses  of  midwives.  I 
began  by  showing  the  fallacy  of  the  statistics  of  Lefort,  which  had 
led  to  so  sweeping  a  demand,  and  the  danger  of  small  private  places 
where  women  were  confined  for  a  low  stipend.  At  that  time  I  had 
to  admit,  even  in  the  best  constructed  and  managed  hospitals,  a 
somewhat  higher  mortality — one  and  one-half  per  cent,  against  one 
per  cent. — than  in  private  practice.  Since  then  the  relation  has  been 
reversed.  While  the  mortality  in  the  cities  has  remained  about  the 
same,  that  in  hospitals  has  been  brought  down  to  less  than  one-half 
of  one  per  cent.  The  explanation  of  this  fact  is  to  be  found  in  the 
strict  adherence  to  antiseptic  and  aseptic  rules  in  hospitals  all  over 
the  civilized  world,  and  the  dereliction  in  this  respect  of  private  prac- 
titioners and  midwives.  This  result  is  so  much  more  wonderful 
when  we  take  into  consideration  how  handicapped  the  hospitals  are 
in  the  race  by  having  a  majority  of  unmarried  patients,  in  whom 
there  is  often  a  disturbing  emotional  element ;  a  comparatively  large 
number  of  primiparae,  in  whom  dangerous  complications  occur  much 
more  frequently  than  in  pluriparae ;  in  having  a  number  of  cases 
brought  in  because  they  offer  difficulties,  and  after  ineffectual  attempts 
at  delivery  have  been  made  outside  of  the  hospital,  most  of  the  time 
by  more  or  less  incompetent  persons ;  in  being  chiefly  used  by  the 
poor,  whose  vital  forces  are  often  impaired  by  debauch,  disease,  want, 
and  worry  ;  and  in  being  to  a  great  extent  utilized  as  schools  for  the 
instruction  of  physicians  and  midwives,  which  used  to  be  the  chief 
cause  of  the  so-called  epidemics  of  puerperal  fever. 

The  public  is  not  aware  of  the  greater  safety  of  hospital  confine- 
ments as  compared  with  private  practice.  This  fact  is  becoming  more 
and  more  known  in  regard  to  general  surgery  and  gynaecological  oper- 
ations, and  it  would  also  be  so  with  reference  to  obstetric  cases  if  it 
were  not  that  general  practitioners  and  midwives  are  interested  in 
having  women  confined  at  home,  and  that  most  women  dislike  to  give 
up  home  comforts  and  the  care  they  may  receive  from  relatives, 
friends,  or  nurses  of  their  own  choice.  But  cases  in  which  capital 
operations,  such  as  Csesarean  section  or  symphyseotomy,  are  to  be 
performed,  should  in  the  large  cities,  as  a  rule,  be  transported,  even 
during  the  labor,  to  a  good  hospital,  where  strictly  aseptic  material  is 
at  command  and  where  skilled  assistance  is  easily  obtained  at  all 
hours.  Furthermore,  pregnant  women  who  are  too  poor  to  secure  a 
good  accoucheur  and  a  good  nurse  ought  to  prefer  the  hospitals,  and  so 
should  those  who  are  not  strictly  poor,  but  who  cannot  secure  proper 
help  at  home.  Several  institutions,  such  as  the  Sloane  Maternity, 
the  Infant  Asylum,  the  Mothers'  Home  and  Maternity,  offer  private 
rooms  for  such  patients,  where  they  for  a  moderate  remuneration  can 
combine  some  home  comforts  with  all  the  advantages  of  well-regulated 


218  XORMAL    LABOR. 

hospitals  administered  by  distinguished  specialists  and  a  trained  staff 
of  doctors  and  nurses. 

Hospital  practice  differs  essentially  from  that  in  private  houses  by 
the  presence  of  a  more  or  less  large  number  of  women  who  await 
their  confinement,  of  women  who  are  in  labor,  and  of  women  who 
have  recently  been  delivered.  There  is,  therefore,  special  danger  of 
one  of  these  women  infecting  others,  and  special  precautions  are 
needed  to  prevent  this  evil.  In  such  institutions  much  stricter  asepsis 
is  called  for  than  in  private  practice,  where,  as  a  rule,  antisepsis  is 
sufficient.  Corrosive  sublmiate  being  the  most  powerful  antiseptic 
drug,  and  inexpensive,  this  is  made  use  of  extensively.  It  is  used  in 
a  1 :  1000  solution  for  cleaning  the  furniture,  and  in  1  :  2000  for  the 
buttocks,  the  abdomen,  and  the  thighs,  as  well  as  the  mucous  mem- 
brane of  the  vulva  of  the  patient,  and  the  hands  of  the  doctors  and 
nurses.  It  is  convenient  to  have  large  bottles,  casks,  or  tanks  filled 
with  a  solution  of  one  part  in  a  thousand  j)arts  of  water, — the  standard 
solidion, — which  can  be  diluted  with  hot  or  cold  water  when  a  weaker 
solution  is  wanted.  In  the  beginning  I  used  also  vaginal  and  intra- 
uterine injections  of  bichloride  of  mercur}'  for  different  purposes,  but, 
having  seen  several  cases  in  wliich  I  thought  this  practice  led  to  serious 
illness  or  death,  I  made  a  special  study  of  the  subject  and  collected 
twenty-three  cases  of  death  due  to  the  intra-uterine  and  vaginal  use  of 
corrosive  sublimate.  From  that  time  I  substituted  creolm  one  per 
cent,  for  the  bichloride  of  mercury  for  injections.^ 

For  disinfection  of  the  hands  and  arms  of  the  doctors  and  nurses, 
they  should  first  be  scrubbed  for  three  minutes  with  a  stiff  nail- 
brush in  very  hot  water,  after  having  removed  all  rings  and  using 
soft  potassa  soap,  which  in  itself  is  an  antiseptic  of  considerable  value. 
Next,  they  should  be  scrubbed  in  a  solution  of  bichloride  of  mercury 
for  a  similar  length  of  tune.  In  order  to  take  away  the  roughness 
caused  by  the  corrosive  subhmate,  it  is  well  to  dip  the  hands  sub- 
sequently into  a  one  per  cent,  emulsion  of  creolm  or  lysol.  For 
further  safety  it  is  well  to  wash  the  hands  and  arms  with  alcohol, 
but  some  institutions  would  object  to  it  on  account  of  its  high  price, 
and  perfect  results  may  be  obtained  without  it.  Some  bacteriologists 
even  belittle  its  value  as  a  germicide,  while  others  believe  it  to  be  the 
most  reliable  of  all.  The  above  enumerated  parts  of  the  patient's  body 
are  cleaned  in  a  smiilar  way,  for  which  the  tincture  of  green  soap  is 
ver}"  ser\dceable. 

All  substances  coming  in  contact  with  the  patient  should  be 
sterilized  by  means  of  moring  steam  under  high  pressure  in  sterilizers, 
which  may  be  obtained  from  the  manufacturers  of  hospital  furniture. 

^  Garrigues,  "Corrosive  Sublimate  and  Creolin,"  Am.  Jour.  Med.  Sci. ,  August, 
1889. 


LYING-IN    INSTITUTIONS.  219 

Instruments  should  be  boiled  for  five  minutes  in  a  solution  of  crude 
carbonate  of  sodium, — tliat  is,  common  washing  soda, — a  flat  table- 
spoonful  for  each  cjuart  of  water.  The  accoucheur  and  his  assistants 
should  don  sterilized  gowns  and  caps,  as  in  surgical  operations. 

It  is  convenient  to  have  a  special  labor-bed,  upon  which  the 
woman  is  placed  when  she  is  somewhat  advanced  in  the  first  stage. 
It  should  be  of  the  height  of  an  operating  table,  and  the  mattress 
covered  all  over  with  rubber  cloth  and  a  sterilized  sheet.  A  pair  of 
solid  round  wooden  sticks  should  be  placed  in  metal  bows  on  the 
sides  at  such  a  distance  that  the  patient  can  easily  get  hold  of  them 
and  use  them  as  support  in  bearing  down.  At  the  lower  end  there 
should  be  stirrups  allowing  the  accoucheur  to  have  the  patient  carried 
down  to  the  end  of  the  bed  and  lie  in  an  easy  dorsal  position,  with 
bent  knees  or  outstretched  legs,  and  free  access  to  the  genitals,  or  to 
have  her  turned  over  into  the  left-side  position.  It  is  also  desirable 
to  have  a  regular  gynjecological  table  arranged  so  as  to  be  able  to 
place  her  in  the  elevated-pelvis  position. 

In  the  delivery-room  the  furniture  should  preferably  be  made  of 
enamelled  iron  and  glass.  The  room  should  contain  all  the  drugs, 
instruments,  apparatus,  and  bottles  used  in  obstetric  work.  All  bottles 
should  be  distinctly  labelled.  There  should  be  a  liberal  supply  of 
glass  or  agate  ware  dishes  for  the  instruments  and  material  used  in 
obstetric  operations,  and  dishes  for  keeping  specimens  for  examina- 
tion. There  should  also  be  a  reliable  faradic  apparatus  in  good 
working  order,  an  apparatus  for  transfusion  and  infusion,  masks  for 
administering  chloroform  and  ether,  gags,  tongue-forceps,  several  hy- 
podermic syringes,  cylinders  filled  with  oxygen,  and  bottles  with  the 
drugs  in  common  use  to  relieve  pain  or  combat  shock,  especially  mor- 
phine, nitroglycerin,  strychnine,  atropine,  tincture  of  digitalis,  and 
camphorated  oil.  The  room  in  which  the  women  are  delivered  is  in 
the  Maternity  Hospital  called  the  "pony-room,"  I  have  in  vain  tried 
to  get  an  authoritative  explanation  of  the  etymology  of  this  term,  and 
offer,  therefore,  the  suggestion  that  pony  here  is  to  be  taken  in  the 
sense  of  a  small  bed,  a  cot,  just  as  it  is  used  in  speaking  of  a  small 
horse  and  a  small  glass?  I  have  found  an  analogy  in  Belgium,  where 
it  is  customary — at  least  it  was  so  forty  years  ago — to  deliver  a 
woman,  even  in  private,  on  a  narrow  bed  called  dne,  which  means  a 
donkey.  A  similar  bed  will  probably  have  been  called  a  pony  in 
English,  and  the  room  in  which  it  was  placed  in  hospitals  then  became 
the  pony-room. 

In  the  construction  of  a  lying-in  hospital  certain  points  deserve 
consideration.  The  ground  should  be  healthy,  not  an  old  dumping- 
ground  filled  up  with  all  sorts  of  offal,  debris,  and  refuse,  as  so  many 
places  are  in  New  York.     Nor  should  the  hospital  be  built  over  an 


220  NORMAL   LABOR. 

old  creek,  for  it  is  a  common  experience  in  New  York  that  such 
houses  are  liable  to  be  malarial.  If  possible,  it  should  be  built  on 
high  ground  with  free  access  of  fresh  air.  It  is  best  in  temperate 
climates  to  have  the  wards  so  situated  as  to  face  east,  west,  and  south. 
Rooms  with  exclusive  northern  exposure  are  apt  to  be  chilly. 

Since  puerperal  women  have  more  abundant  secretions  than  other 
patients,  especially  perspiration  and  lochial  discharge,  the  air  is  loaded 
with  animal  effluvia.  There  should,  therefore,  be  calculated  more 
space  for  each  patient  than  in  ordinary  hospitals,  say  from  fifteen 
hundred  to  two  thousand  cubic  feet.  The  best  ventilation  should  be 
provided,  in  which  respect,  I  think,  architectural  art  has  still  much  to 
learn.  I  have  never  yet  seen  a  hospital  or  private  house  in  which  the 
air  could  be  sufficiently  renewed  without  opening  the  windows ;  but 
as  drafts  are  sometimes  injurious,  the  air  should  be  led  in  through 
wire  and  flannel  screens,  distributing  it  over  a  large  surface,  and  at 
the  same  time  breaking  it  up  into  fine  currents.  It  is  not  enough  to 
rely  on  the  circulation  of  air  being  produced  merely  by  free  commu- 
nication with  the  outer  air  and  difference  in  temperature.  In  a  good 
hospital  the  fresh  air  should  be  driven  in  by  mechanical  force,  especi- 
ally fans  kept  moving  in  the  lower  part  of  the  house,  and  distributing 
fresh  air  through  conduits  into  each  room.  There  should  likewise  be 
canals  for  the  exit  of  the  vitiated  air,  which  to  advantage  may  be  led 
into  a  main  shaft,  where  it  is  forced  upward  by  heat  or  mechanical 
device.  It  is  necessary  to  lead  the  fresh  air  from  outside  the  building 
through  closed  shafts  and  pipes,  and  not  take  it  from  the  cellar  under 
the  building  itself. 

The  mode  of  heating  calls  also  for  close  attention.  There  is  hardly 
any  doubt  that  an  open  fire  giving  the  smoke  off  through  a  flue  to 
the  air  above  the  house  is  the  healthiest  way  of  warming  a  room,  but 
it  entails  much  loss  of  heat  and  demands  a  great  deal  of  care.  The 
next  best  way  of  heating  is  by  means  of  stoves,  which  are  more 
economical ;  but  in  a  large  building  great  saving  is  obtained  in  regard 
to  fuel  and  labor  by  having  some  system  by  which  the  heat  is  gener- 
ated in  one  place,  from  which  it  is  distributed  through  pipes.  Either 
hot  air,  steam,  or  hot  water  may  be  used  for  circulating  in  the  pipes. 
Hot  air  is  apt  to  become  too  dry,  and  it  is  often  difficult  to  obtain  an 
even  distribution  of  the  heat,  some  rooms  being  cold  while  others  are 
overheated.  Steam  and  water  only  heat  the  air  in  the  rooms,  and  do 
not  introduce  fresh  air ;  but  upon  the  whole  steam-heating  seems  to 
be  the  most  practical,  and  its  drawbacks  must  then  be  counterbalanced 
by  the  ventilating  apparatus. 

There  should  be  an  abundant  supply  of  hot  and  cold  wate)\  and 
the  best  system  of  trapping  in  order  to  prevent  sewer-gas  from  enter- 
ing the  rooms  through  the  drainage-pipes. 


LYING-IN    INSTITUTIONS.  221 

Old-fashioned  privies  with  their  putrefying  animal  matter  contain 
a  danger  for  parturient  and  lying-in  women  from  which  we  must  pro- 
tect them.  In  modern  lying-in  hospitals  there  will,  of  course,  be 
water-closets  with  running  water,  but  it  is  not  enough  to  partition 
them  off  from  the  ward  with  a  few  boards.  They  should  be  entirely 
removed  and  placed  either  in  a  separate  building  or  on  the  other  side 
of  a  corridor,  or  an  intervening  room  in  which  there  is  a  constantly 
open  window.  In  the  water-closets  themselves  there  should  also  be 
an  open  window.  The  hoppers  should  be  kept  scruj^ulously  clean, 
and  for  the  disinfection  of  the  pipes  it  is  well  daily  to  throw  some 
cheap  disinfectant  into  them,  such  as  chloride  of  lime  or  sulphate  of 
zinc.  To  use  odoriferous  substances,  such  as  carbolic  acid,  thymol, 
or  camphorette,  for  this  purpose,  is  not  to  be  recommended,  as  they 
are  apt  to  conceal  the  danger  instead  of  eradicating  it. 

Bedpans  ought  to  be  removed  as  soon  as  used,  emptied  into  the 
water-closets,  cleaned,  and  disinfected.  Dressings  ought  to  be  col- 
lected in  closed  cans  and  burned. 

Separation  of  Patients. — Women  who  are  awaiting  their  confine- 
ment, the  parturient  and  newly  delivered,  and  patients  Avith  pro- 
tracted diseases  should  be  kept  separate  from  one  another.  In  the 
New  York  Maternity  women  who  had  no  homes  were  often  admitted 
as  early  as  four  months  before  confinement,  and  the  service  was  then 
two  or  three  times  as  large  as  it  is  now,  so  that  there  was  a  large 
number  of  practically  well  persons,  whom  it  was  particularly  difficult 
to  keep  submitted  to  the  strict  disciplinary  rules  of  the  hospital. 
When  one  of  these  patients  is  taken  in  labor,  she  should  be  removed 
from  the  others,  both  for  her  own  sake  and  for  theirs.  She  should 
have  quiet,  and  have  special  care,  and  the  others  should  be  spared 
the  view  of  the  sufferings  which  await  them.  To  have  patients  with 
suppuration  or  other  pathological  conditions  in  the  room  in  which 
parturition  takes  place  and  the  newly  confined  women  are  kept,  ex- 
poses others  to  infection. 

Furthermore,  sick  puerperal  women  ought  to  be  separated  from 
the  well.  Even  in  the  smallest  lying-in  institutions  there  ought  to  be 
a  sick-room  always  ready  for  use.  If  there  is  no  such  place  set  apart, 
and  a  special  room  must  be  provided  for  isolating  a  patient  when  she  is 
deemed  to  be  dangerous  to  the  other  patients,  the  measure  will  not 
be  resorted  to  often  enough  and  early  enough  to  yield  all  the  advan- 
tages which  might  be  derived  from  it.  This  does  not  mean  that  every 
patient  whose  lying-in  period  shows  the  slightest  deviation  from  the 
normal  need  be  separated  from  the  others.  All  i)atients  with  a  slight 
rise  in  temperature,  with  a  little  fetor  of  the  lochial  discharge,  and 
with  local  pelvic  inflammation,  I  left  in  the  wards.  The  only  kind  of 
patients  I  removed  were  those  afTected  with  i)uorperal  diphtheria,  and 


222  NORMAL   LABOR. 

they  were  transported  as  soon  as  the  diagnosis  was  made.  As  a  rule, 
a  sudden  rise  in  temperature  to  from  103°  to  105°  F.  cahed  attention 
to  their  dangerous  condition.  They  were  then  taken  to  the  sick-ward, 
where  an  inspection  was  made  and  showed  the  diphtlieritic  infiltration. 

The  sick  patients  must  have  their  own  day  and  night  nurses  who 
have  nothing  else  to  do  but  to  watch  them,  feed  them,  nurse  them, 
give  them  medicine,  cheer  them  up,  and  make  them  feel  as  comfort- 
able as  their  sad  condition  allows.  They  should  be  treated  by  other 
physicians,  so  that  the  chief,  once  having  shown  what  is  to  be  done, 
may  leave  the  treatment  in  their  hands.  By  good  care  even  seem- 
ingly desperate  cases  may  sometimes  be  saved  through  the  devotion 
of  assistants  and  nurses. 

The  sick-ward  should,  of  course,  have  its  own  mstruments,  which 
never  should  be  used  for  the  normal  puerperae. 

A  regular  and  rapid  rotation  in  the  use  of  the  wards  is  of  great 
importance  as  a  safeguard  against  infection  in  lying-in  hospitals.  Even 
before  the  new  era  in  Maternity  Hospital,  when  we  used  the  wards  in 
a  hap-hazard  way,  we  noticed  that,  as  often  as  a  ward  was  emptied, 
cleaned,  and  fumigated,  the  patients  were  free  from  fever  for  a  week. 
I  therefore  introduced  a  regular  rotation,  each  ward  of  six  or  nine 
beds  being  only  used  for  one  set  of  patients,  and  each  patient  staying 
only  nine  days,  when  she  was  transferred  to  the  convalescent  ward, 
in  which  she  stayed  a  few  days  longer,  unless  some  abnormality  in 
her  condition  called  for  longer  rest  and  treatment.  Every  time  the  last 
patient  reached  her  ninth  day  the  ward  was  fumigated,  aired,  and 
disinfected. 

Special  attention  should  be  paid  to  the  laundry.  It  is  not  enough 
to  wash  sheets,  blankets,  pillow-cases,  and  personal  underwear  after 
each  confinement.  If  a  patient  is  so  sick  as  to  make  it  likely  or  sure 
that  she  is  suffering  from  puerperal  infection  and  septicaemia,  all 
clothes  that  she  has  used  on  her  person  or  in  her  bed  should  be 
washed  and  disinfected  separately  from  the  linen  used  by  the  well 
women.  In  Maternity  Hospital  I  had  large  casks  holding  all  the  bed- 
clothes from  one  patient  filled  with  the  undiluted  solution  of  corro- 
sive sublimate,  one  to  one  thousand,  and  the  clothes  immersed  for  an 
hour  and  washed  separately  before  going  to  the  laundry,  where  they 
were  mixed  with  the  other  linen. 

Tlie  Neio  York  Maternity  Hospital. — In  the  year  1888  I  had  the 
pleasure  of  laying  the  plan  for  the  new  building  of  the  New  York 
Maternity  Hospital  on  Blackwell's  Island,  the  details  of  which  were 
carried  out  by  Mr.  Frederick  C.  Withers,  architect,  some  of  whose 
drawings  I  with  his  kind  permission  reproduce  in  Figs.  230,  231,  232. 

This  hospital  being  an  annex  to  Charity  (now  City)  Hospital,  the 
women  awaiting  their  confinement,  those  who  had  been  confined  nine 


LYING-IN    INSTITUTIONS. 


223 


days  ago  or  more,  doctors,  nurses,  the  drug-store,  kitchen,  and  store- 
rooms were  housed  in  other  buildings,  so  that  tlie  new  building  should 
be  used  exclusively  for  parturient  women  and  puerperae  delivered 
within  nine  days.  Since  tlie  building  was  to  be  constructed  on  an 
island  with  an  abundance  of  ground  belonging  to  the  city,  I  chose  to 
give  it  the  shape  of  a  cross,  whereby  the  wards  were  widely  separated 

Fig.  230. 


The  New  York  Maternity  Hospital,  Blackwell's  Island.    East  elevation. 

from  one  anotlier  and  liglit  and  air  had  free  access.  I  made  the 
delivery-room  the  centre  of  the  whole  service,  and  had  three  wards, 
each  destined  for  twelve  beds,  going  out  at  right  angles  towards  the 
east,  south,  and  west.  Contiguous  with  the  south  wing,  but  entirely 
separated  from  it,  is  an  Isolation  Department,  composed  of  four  sepa- 
rate rooms  and  a  bath-room  and  water-closet. 


Fig.  231. 


New  York  Maternity  Hospital.    North  elevation. 

At  the  opposite  end  of  the  building  are  two  rooms  for  operative 
cases,  an  office  for  the  doctor  on  duty,  and  a  room  for  the  head- 
nurse.  Between  the  department  for  healthy  women  and  the  Isolation 
Department  is  a  kitchen,  and  each  ward  has  its  own  linen-closet  and 
water-closet. 

There  is  no  direct  communication  between  the  wards  and  the  de- 
livery-room, but  at  each  of  the  four  corners  of  the  latter  is  a  so-called 
ombra,  a  space  covered  with  a  roof  and  having  three  doors,  one 
leading  to  the  delivery-room  and  two  opening  into  the  two  con- 
tiguous wards.     By  this  disposition  no  air  from  a  ward  can  enter  the 


224 


NORMAL   LABOR. 


delivery-room,  and  the  attendants  may  either  traverse  the  room  or  go 
around  it,  passing  through  wards  and  ombras  without  being  exposed 
to  rain  and  snow.  After  delivery  the  patient  is  transferred  to  the 
ward  then  in  use. 

I   had    planned    the   building  so   as   to   have   the   administrative 
department  occupying  the  northern  end,  but  a  higher  power  turned  it 

Fig.  232. 


New  York  Maternity  Hospital,  Blackwell's  Island.    Plan  of  ground  floor. 


ninety  degrees,  disturbing  the  whole  orientation  so  that  north  became 
east,  and  so  forth. 

In  the  conduct  of  labor  in  a  lying-in  hospital  the  obstetrician 
should  follow  the  rules  of  aseptic  surgery.  He  and  his  assistants 
should  wear  sterilized  gowns  and  caps,  and  all  sheets,  towels,  and 
pads  used  should  be  sterilized  by  prolonged  exposure  to  moving 
steam  under  pressure.  All  instruments  should  be  boiled  for  five 
minutes  in  a  solution  of  washing  soda  (a  tablespoonful  to  each  quart 
of  water). 


PART    IV.— NORMAL    PUERPERY. 


Definition. — The  puerpery,  puerperium,  or  puerperal  state  is  the 
period  following  labor.  It  has  a  distinct  starting-point, — namely,  the 
moment  the  after-birth  has  been  removed  from  the  maternal  body, — 
but  its  end  is  not  so  well  marked,  and  therefore  its  length  varies,  dif- 
ferent authors  placing  the  limit  differently.  According  to  etymology, 
— -puei\  a  child,  and  jmrio,  I  give  birth  to, — a  puerpera  is  a  woman 
who  has  recently  given  birth  to  a  child.  The  laity  is  inclined  to  make  a 
special  period  of  the  time  a  woman  stays  in  bed  after  delivery,  which 
with  most  people  means  nine  days.  But  this  varies  enormously. 
The  Indian  squaw  does  not  take  to  her  bed  at  all,  but  follows  her 
tribe  as  soon  as  labor  is  over.  The  writer  has  known  a  poor  un- 
married woman  who  gave  birth  to  her  tenth  child,  and  who  had  never 
rested  more  than  one  hour  after  delivery,  when  she  returned  to  her 
hard  work  of  washing  clothes  or  scrubbing  the  floor.  In  the  lying-in 
hospital  in  Munich,  women  are  kept  only  five  days  after  delivery. 
On  the  other  hand,  it  is  not  rare  for  women  who  can  take  care  of 
themselves  to  stay  two  weeks  in  bed,  and  some  eminent  accoucheurs 
recommend  even  a  lying-in  period  of  three  weeks.  The  expressions 
"  lying-in  month"  and  "  monthly  nurse"  show  that  in  the  public  mind 
the  puerperal  state  lasts  a  month.  The  author  some  years  ago  made 
a  special  study  of  the  question  of  "  Rest  after  Delivery,"  ^  and  came  to 
the  conclusion  that  the  patient  ought  to  be  kept  quietly  in  bed,  alter- 
nately on  her  back  and  on  her  sides,  until  the  uterus  has  diminished 
sufficiently  to  sink  below  the  pelvic  rim,  and  until  all  raw  surfaces  in 
the  obstetric  canal  are  covered  with  granulations  or  healed.  The  time 
a  woman  is  kept  in  bed  after  labor  varying  so  much,  it  cannot  be  used 
as  a  standard  for  the  length  of  tlie  puerperal  state.  French  authors 
usually  look  upon  the  return  of  menstruation  as  the  end  of  the  puer- 
perium, but  this  being  based  only  upon  the  unnatural  habit  of  women 
in  that  country  of  letting  other  women  nurse  their  children,  it  hardly 
deserves  recognition  in  a  disquisition  about  the  normal  childbed. 
From  a  scientific  stand-point  we  must  say  that  the  puerperal  state 
extends  until  the  time  w^ien  involution  is  finished, — that  is,  until  the 
genital  canal  and  the  abdominal  w^all  have  returned  to  their  former 
condition,  or  rather  have  approximated  it  as  much  as  they  ever  will, 
because  a  woman  who  has  borne  a  child  will  never  become  entirely 

^  Garrigues,  Amer.  Jour.  Obst.,  1880,  vol.  xiii.  pp.  845-864. 

15  225 


226  NORMAL    PUERPERY. 

like  herself  as  she  was  before  pregnancy  and  labor  took  place.  As 
we  presently  shall  see,  this  retrograde  and  reparative  process  is  not 
finished  before  sixty  or  seventy  days,  or  even  four  or  five  months 
after  childbirth. 


CHAPTER    I. 
CONDITION    OF   THE   MOTHER. 

While  during  pregnancy  there  was  a  strong  current  of  nutritive 
substances  going  from  the  mother  to  the  child,  by  which  its  body 
gradually  was  developed,  after  the  end  of  labor  the  tide  turns  and 
there  is  a  strong  current  of  waste  material  going  from  the  genitals 
inward,  which  explains  the  peculiar  vulnerability  so  peculiar  to  puer- 
peral women.  The  waste  material  produced  by  the  process  of  invo- 
lution chiefly  finds  its  way  out  of  the  maternal  organism  through  a 
peculiar  discharge  from  the  inside  of  the  womb  called  lochia,  an 
abundant  perspiration,  and  the  urine. 

Temperature. — It  is  quite  common  for  the  newly  delivered  woman 
to  feel  chilly  and  even  to  shiver.  A  rise  in  temperature  to  100°  or 
100.5°  F.  is  so  common  that  it  must  be  regarded  as  normal.  It  is 
especially  marked  in  the  late  afternoon,  while  in  the  morning  the  tem- 
perature is  usually  slightly  below  the  normal.  The  rise  is  doubtless 
due  to  the  combustion  of  effete  material.  Before  the  use  of  antiseptics, 
higher  temperatures  were  quite  common  after  three  or  four  days,  and 
were  attributed  to  the  beginning  milk  secretion.  This  so-called  milk 
fever  has  disappeared  with  the  improved  management  of  parturient 
and  puerperal  women.  Higher  degrees  of  temperature  are  mostly 
due  to  some  inflammation,  to  retention  of  faeces  or  lochia,  or  to  emo- 
tions ;  and  their  cause  should  be  carefully  investigated,  in  order  to  be 
able  to  meet  all  indications. 

Pulse. — The  frequency  of  pulsation  diminishes  to  70  or  60  beats 
in  the  minute,  or  occasionally  it  even  goes  down  to  50  or  40,  and 
the  pulse  not  rarely  has  an  intermittent  character.  This  slowness  is 
probably  due  to  a  diminution  in  the  work  the  heart  is  called  upon 
to  perform  by  the  elimination  of  the  child,  the  closure  of  many  chan- 
nels through  which  the  blood  heretofore  circulated,  and  the  loss  of 
blood  during  labor. 

Perspiration. — The  perspiration  incident  on  the  exertions  of  labor 
does  not  cease  with  it,  but  continues  and  even  increases  after  its 
termination. 

Respiration  becomes  easier  after  the  expulsion  of  the  child,  its 
frequency  varying  between  12  and  24  per  minute.  In  consequence 
of  the  diminished  compression  of  the  lungs,  their  capacity  increases. 


CONDITION    OF   THE    MOTHER.  227 

The  appetite  is  diminished,  while  the  thirst,  in  consequence  of  the 
loss  of  water  through  perspiration,  lochial  discharge,  and  increased 
urinary  secretion,  is  more  marked. 

The  bowels  are  constipated,  which  may  be  due  to  the  administration 
of  an  enema  before  delivery,  to  the  smaller  amount  of  food  taken,  and 
to  its  composition,  which  does  not  leave  much  undigested  residue. 

The  urine  is  increased  in  amount,  at  the  same  time  that  it  contains 
less  urea.  On  the  other  hand,  it  contains  some  albumin,  and  often 
sugar.  The  former  is  probably  due  to  the  destruction  and  absorption 
of  much  albuminoid  tissue  from  the  genitals,  the  latter  to  absorption 
from  the  breasts.  The  urine  also  frequently  contains  hyaline  casts 
and  epithelial  cells  from  the  different  parts  of  the  uropoietic  system 
and  numerous  leucocytes. 

It  is  noticeable  that  puerperae,  as  a  rule,  do  not  feel  so  frequent  a 
desire  to  urinate  as  before,  an  interval  of  twelve  hours  not  being  rare, 
unless  orders  are  given  to  let  the  patient  urinate  or  to  draw  the  urine 
more  frequently.  This  sluggishness  may  be  due  to  the  laxity  of  the 
abdominal  wall,  which  allows  great  expansion  of  the  bladder.  Per- 
haps, also,  the  strong  anteflexion  of  the  uterus  causes  a  flexion  of 
the  urethra.  Often  it  is  bruised  and  swohen  from  compression  be- 
tween the  child's  head  and  the  symphysis  pubis. 

Lochia. — The  lochial  discharge  consists  at  first  of  pure  blood; 
after  three  or  four  days  it  becomes  more  serous  for  the  next  three  or 
four  days,  and  finally  it  becomes  mucopurulent.  According  to  this 
varying  appearance  it  is  called  lochia  cruenta,  or  rubra,  lochia  serosa, 
and  lochia  alba,  lactea,  or  mucosa.  But,  while  this  sequence  is  the  norm, 
there  obtains  considerable  variability  in  respect  to  the  character  of 
the  lochial  discharge  in  women  who  otherwise  are  in  good  health. 
Especially  it  is  quite  common  to  see  the  discharge  repeatedly  become 
bloody  again.  Its  duration  varies  also  considerably,  between  two  and 
six  weeks.  In  those  who  do  not  nurse  their  children  it  is  apt  to  last 
twice  as  long  as  in  those  who  do.  The  fluid  has  a  peculiar  nauseous 
odor.  It  contains  albumin,  mucin,  fat,  cholesterin,  and  various  salts. 
Its  reaction  is  neutral  or  acid.  Microscopical  examination  reveals  red 
blood-corpuscles,  pus-corpuscles,  and  epithelial  cells  in  it.  After  two 
or  three  days  numerous  microbes  are  found  in  it, — single  cocci, 
staphylococci,  and  bacilli.  They  originate  partly  from  those  found  in 
the  vagina  before  delivery,  and  partly  they  enter  from  Avithout.  In 
normal  cases  lochia  taken  from  the  interior  of  the  uterus  do  not  con- 
tain germs.  When  injected  under  the  skin  the  fluid  produces  fu- 
runcles, and  its  retention  in  the  cavity  of  the  uterus  or  the  vagina  is 
apt  to  cause  a  rise  in  temperature.  When  it  stagnates,  it  acquires  a 
fetid  odor,  the  saprophytes  floating  in  the  air  finding  a  favorable  soil 
in  it  for  propagation.     Its  total  amount  is  hard  to  ascertain,  and  the 


228  ^'OKMAL  PUERPERY. 

few  who  have  tried  to  measure  it  have  arrived  at  rather  discrepant 
results,  varying  between  one  pound  and  three  pounds  during  the  first 
eight  to  eleven  days. 

Involution  of  the  Uterus. — Immediately  after  the  expulsion  of  tlie 
placenta  the  uterus  forms  a  hard  ball  not  mounting  more  than  four 
fmger-breadths  over  the  symphysis  pubis,  but.  the  intense  contraction 
subsiding,  it  rises  to  within  an  inch  of  the  umbilicus,  and  is  the  next 
day  often  found  an  inch  above  this  point.  At  first  the  contraction 
has  an  intermittent  character,  contraction  and  relaxation  alternating 
with  each  other,  but  soon  a  permanent  size  is  reached,  and  after  that 
this  alternation  ceases  and  henceforth  the  uterus  steadily  diminishes 
in  size.  At  the  end  of  the  second  week  the  fundus,  when  raised  up, 
is,  however,  still  an  mch  higher  than  in  the  ununpregnated  condition, 
and  at  the  end  of  the  third  week  it  is  yet  half  an  inch  higher  than  in 
the  non-puerperal  state.  A  corresponding  diminution  takes  place  in 
the  lateral  and  anteroposterior  cUniensions. 

The  weight  of  the  uterus  decreases  in  a  similar  manner.  Imme- 
diately after  delivery  it  weighs  from  twenty-two  to  twenty-four  ounces  ; 
at  the  end  of  the  flrst  week,  from  nmeteen  to  twenty-one ;  at  the  end 
of  the  second,  from  nme  to  eleven ;  at  the  end  of  the  third,  from  five 
to  seven ;  and  it  does  not  reach  its  normal  weight,  which  averages 
an  ounce  and  a  half,  before  the  end  of  the  second  month.  It  appears 
from  these  figures  that  the  uterus  has  lost  but  little  in  weight  at  the 
end  of  the  first  week,  that  the  greatest  diminution  takes  place  during 
the  second  week,  and  that  at  the  end  of  the  third  it  is  still  three  or 
four  times  heavier  than  the  non-puerperal  uterus. 

The  immediate  diminution  in  size  following  the  expulsion  of  the 
placenta  is  due  to  muscular  contraction  and  escape  of  some  of  the 
blood  filling  the  uterine  vessels,  but  the  next  day  fatty  degeneration 
and  gradual  absorption  of  the  muscle-cells  begin  and  continue  until 
the  end  of  involution.  It  has  also  been  found  that  towards  the  end  of 
pregnancy  the  muscle-cells  contain  large  vacuoles  filled  with  glycogen, 
which  is  pressed  out  by  the  powerful  contraction  following  childbirth. 

The  separation  between  the  ovum  and  the  uterus  takes  place  in 
the  loose  ampullar  layer  of  the  decidua  (Fig.  233).  Most  of  what  is 
left  is  subsec{uently  destroyed  and  the  debris  eliminated  as  part  of  the 
lochia.  But  the  deepest  parts  of  the  decidua  remain,  and  from  the 
columnar  epithelium  of  the  bottom  of  the  utricular  glands  a  new 
layer  spreads  over  the  inner  surface  in  the  course  of  twenty  or 
twenty-five  days. 

The  placental  site  is  rough  and  often  distinguished  by  clots  pro- 
truding from  the  sinuses.  Some  of  the  sinuses  had  already  become 
closed  towards  the  end  of  pregnancy.  The  others  are  now  obliterated 
by  blood-clots,  which  become  organized  by  cell  proliferation,  starting 


CONDITION    OF    THE    MOTHER. 


229 


from  the  endothelium  and  from  leucocytes,  and  formmg  young  con- 
nective tissue.  The  work  of  reparation  is  slowest  in  this  place,  so 
that  sometimes  the  site  is  still  recognizable  four  or  five  months  atler 
labor. 

Immediately  after  the  birth  of  the  child,  and  still  more  so  after 
the  expulsion  of  the  placenta,  the  uterus  becomes  strOngly  anteflexed, 
the  fundus  lying  up  against  the  anterior  abdominal  wall  and  the  cervix 

Fig.  233. 


The  microscopical  appearance  of  the  inside  of  the  uterus  immediately  after  delivery.    (Zweifel.) 
a,  mucosa ;  6,  muscularis ;  1,  opened  utricular  glands  ^vith  columnar  epithelium ;  2,  blood-vessels. 


following  the  direction  of  the  vagina  (Fig.  234).  The  cervix  is  long 
and  soft  and  the  os  more  or  less  torn.  The  contraction  ring  is  well 
marked,  but  not  the  internal  os,  the  lower  uterine  segment  and  the 
cervix  forming  a  long  tube  with  thin  walls.  The  difference  between 
the  upper  and  the  lower  part  of  the  uterus  disappears,  however,  in 
the  course  of  a  few  days,  the  contraction  ring  approaching  the  internal 
OS  more  and  more  until  it  blends  with  it.  On  a  section  of  a  woman 
who  died  on  the  sixth  day^  there  was  no  longer  any  difference 
between  an  upper  and  a  lower  segment,  but  the  whole  wall  was  three 
times  thicker  than  before  pregnancy.  It  had  also  receded  nearly 
entirely  below  the  pelvic  brim.     The  internal  os  remains  so  soft  that 

1  A.  H.  F.  Barbour,  The  Anatomy  of  Lalior,  Edinhureh,  1889,  PI.  XI. 


230 


NORMAL   PUERPERY. 


a  fmger  may  be  passed  through  it  till  the  end  of  the  second  week, 
and  the  external  os  remains  open  still  longer. 

The  anteflexion  increases  during  the  first  weeks  of  the  puer- 
peral state,  so  that  the  highest  point  of  the  uterus  felt  through  the 
abdominal  wall  is  no  longer  the  fundus  but  some  point  of  the  poste- 


FiG.  234. 


-^^. 


Sagittal  section  of  the  pelvic  organs  of  a  puerpera  on  tlie  second  day  after  delivery.    ( Ahlfeld.) 


rior  surface  (Fig.  235).  Later  the  uterus  gradually  returns  to  its 
normal  shape. 

The  involution  of  the  vagina  is  slower  and  more  imperfect  than 
that  of  the  uterus.  When  this  canal  has  once  been  distended  by  the 
passage  of  a  child,  it  hardly  ever  regains  its  original  dimensions  and 
resiliency,  the  difference  being  particularly  marked  at  the  entrance, 
which  is  nearly  always  more  or  less  torn. 

The  hymen,  that  by  coition  had  only  been  ruptured  so  as  to  form 
two  or  more  flaps,  in  consequence  of  bruising  followed  by  gangrene 
sustains  a  real  loss  of  substance,  its  remnants  shrinking  to  a  few 
wart-like  protuberances  called  carunculce  myrtiformes^  one  of  which  is 
nearly  always  found  on  each  lateral  aspect  of  the  entrance  to  the 
vagina. 

The  labia  majora  remain  more  flaccid  and  often  gaping.  The 
abdominal  wall  is  also  slow  to  contract  and  never  regains  its  former 
elasticity.     The  tears  of  the  corium,  which  we  have  noticed  during 


CONDITION    OF   THE   MOTHER. 


231 


pregnancy  as  purple-colored  streaks,  leave  white  scars  running  more 
or  less  perpendicularly  and  marked  by  fine,  close  lines  intersecting 
them  at  right  angles.  In  that  condition  they  are  properly  called  strice 
albicantes. 

If  the  woman  has  not  been  carefully  bandaged,  gets  up  too  soon, 
or  resumes  hard  work  while  all  the  tissues  are  still  soft  and  yielding, 
the  aponeurosis  of  the  flat  abdominal  muscles  and  the  superficial 
fascia  become  thinned  and  stretched,  so  that  the  recti  muscles  separate 
from  each  other  and  the  intestines  are  felt  in  the  gap,  and,  as  it  were, 
right  under  the  skin.  Even  if  the  thinning  of  the  abdominal  wall  does 
not  go  so  far  as  to  produce  such  a  diastasis,  it  is  not  rare  that  the 


Fig.  235. 


Sagittal  section  of  pelvic  organs  in  puerperium.    (Stratz.)    Day  of  lying-in  period  unknown,  but 
retther  late.    Uterus  in  pelvis,  strongly  antefiexed. 

abdomen  protrudes  more  forward,  while  it  is  an  exception  to  see  it 
return  entirely  to  its  former  shape. 

In  some  women  the  uterus  sinks  behind  the  symphysis  in  five 
days,  but  in  most  it  takes  about  two  weeks  to  do  so.  During  the 
first  three  or  four  days  the  patient  feels  painful  contractions  of  the 
uterus, — so-called  after-pains.  These  are,  however,  much  more 
common  in  pluriparae  than  in  primiparse,  and  are,  therefore,  rather 
due  to  defective  contractions  than  to  too  strong  ones,  a  theory  that  is 
corroborated  by  the  beneficent  effect  of  ergot. 

The  uterine  souffle,  which  during  pregnancy  was  heard  in  the 
sides  of  the  uterus,  may  in  most  cases  be  perceived  for  four  or  five 


232 


NORMAL   PUERPERY. 


days  after  delivery,  a  cogent  proof  that  it  is  independent  of  the 
placenta. 

It  is  not  only  the  uterus  and  the  external  genitals  that  shrink 
after  delivery ;  the  whole  body  loses  on  an  average  a  pound  a  day 
during  the  first  nine  days,  and  often  this  continues  long  after  the 
woman  is  up  and  about,  so  that  she  regains  much  of  her  shapeliness 
which  was  lost  during  pregnancy. 

The  Breasts. — During  the  first  few  days  the  secretion  of  the 
mammary  glands  is  small  in  amount,  indeed  often  not  sufficient  to 
satisfy  the  hunger  of  the  child.  It  is  uneven,  being  composed  of  a 
thin  serum  with  thick  yellowish  streaks,  and  continues  to  show  the 
microscopical  appearance  of  colostrum  (Fig.  138,  p.  96).  About  the 
fourth  day  the  breasts  become  full,  hard,  and  tense,  and  the  secretion 
becomes  even,  thin,  and  of  a  bluish-white  color,  and  is  hereafter 
called  mUk.  This  is  a  fluid  composed  of  nearly  nine  parts  of  water 
and  a  little  over  one  part  of  solid  substance.     One  thousand  parts  of 

Fig.  236. 


cv 


Acini  of  mammary  gland  during  lactation.  (C.  Heitzmann.)  CE,  cuboidal  epithelium  ;  F,  fat- 
globules,  stained  black  with  osmic  acid,  and  seen  both  in  the  cells  and  in  the  central  cavity  of  the 
acini ;  CV,  connective-tissue  frame  with  blood-vessels.    Magnified  six  hundred  diameters. 


milk  contain  889  parts  of  water,  39.24  casein,  26.66  butter,  43.64 
milk  sugar,  and  1.38  inorganic  salts,  especially  phosphate  of  calcium. 
Milk  contains  all  the  substances  needed  for  a  complete  diet, — albu- 
minoids, fats,  and  hydrocarbons, — in  a  form  that  is  easily  asshnilated. 
It  is  the  natural  food  for  the  child  during  the  first  nine  months  of  its 
life,  and  contains  all  the  ingredients  needed  to  build  up  its  body 
during  that  time.  The  fat  is  formed  in  fine  globules  in  the  interior  of 
the  cuboidal  cells  lining  the  acini  of  the  mammary  gland,  whence  it 
enters  their  central  cavity  and  is  pressed  by  elasticity  into  the  lacti- 
ferous ducts  (Fig.  236),  from  which  the  child  sucks  it  out  by  forming 


THE    CARE    OF    THE    MOTHER. 


233 


a  vacuum  in  its  mouth.  Milk  forms  an  even  emulsion  with  very  fine 
fat  globules  (Fig.  237).  Colostrum  contains,  besides  fat  globules  of 
very  unequal  size,  colostrum  globules,  which  are  epithelial  cells  in 
fatty  degeneration.     It  also  contains  albumin  and  coagulates  by  heat. 

Fig.  237. 


Mieroscoijical  appearance  of  woman's  milk 


The  mother's  food  has  great  influence  on  the  composition  of  the 
milk,  and  drugs  given  her  are  found  in  it  and  thus  reach  the  child  she 
nurses. 

Milk  contains  many  staphylococci  and  even  streptococci,  microbes 
which  must  have  found  their  way  in  through  the  canals  of  the  nipples, 
but  under  ordinary  circumstances  they  neither  harm  the  mother  nor 
the  child. 


CHAPTER    11. 

THE    CARE    OF   THE    MOTHER. 

The  woman  who  has  recently  given  birth  to  a  child  needs  a  good 
deal  of  care,  in  order  to  prevent  the  change  from  a  normal  lying-in 
period  to  an  abnormal  one,  and  to  restore  her,  as  far  as  possible,  to 
her  pristine  condition.  Even  in  private  practice  pulse  and  tempera- 
ture should  be  taken  twice  a  day  and  recorded  in  writing.  The  best 
time  for  this  is  about  eight  o'clock  in  the  morning  and  between  six 
and  seven  in  the  evening.  In  lying-in  hospitals  the  result  ought  to  be 
recorded  graphically,  so  as  to  enable  the  visiting  physician  to  satisfy 


234  NORMAL   PUERPERY. 

himself  at  a  glance  of  the  condition  of  the  patients.  Since  the  arrival 
of  the  doctor  is  apt  to  cause  a  little  excitement,  it  is  better  to  have 
pulse  and  temperature  taken  by  the  nurse. 

On  account  of  the  perspiration  pearling  on  the  skin  of  the  puer- 
pera,  she  should  be  carefully  guarded  against  draughts ;  on  the  other 
hand,  she  should  have  plenty  of  fresh  air,  the  more  so  as  evaporation 
of  the  lochial  discharge  vitiates  the  atmosphere,  or  at  least  makes  it 
unpleasant  to  breathe  and  smell.  If  possible,  I  prefer  in  cold  weather 
to  keep  an  open  window  in  a  neighboring  room  rather  than  in  that 
where  the  patient  lies.  The  temperature  of  the  room  should  be  kept 
at  about  70°  F.  The  patient  should  be  covered  enough  to  feel  com- 
fortable, but  not  so  much  as  to  increase  unnaturally  the  perspiration. 
The  room  should  be  kept  light  in  daytime,  and  only  too  glaring  a 
sunlight  ought  to  be  mitigated  by  pulling  down  the  shades.  There  is 
no  call  for  a  darkened  room.  The  puerpera  should  not  be  treated  as 
a  sick  person,  and  most  vital  functions  are  benefited  by  light.  During 
the  night  it  is  convenient  and  proper  to  have  a  weak  flame  burning, 
and  to  screen  it  from  both  mother  and  child. 

In  regard  to  diet,  I  find  it  pretty  safe  to  satisfy  the  appetite  of 
the  puerpera.  During  the  first  twenty-four  hours  I  let  her  take  only 
milk,  tea,  coffee,  beef  tea,  and  oatmeal  gruel.  On  the  second  day  I 
add  a  couple  of  eggs  or,  if  the  woman  desires  it,  soup  with  sweet- 
bread or  pigeon,  or  chicken  fricassee.  Then  come  broiled  chicken, 
mutton-chops,  and  beefsteak,  with  bread  and  butter.  Vegetables  are 
not  so  easy  to  digest  as  the  more  albuminoid  foods,  and  fruit  some- 
times causes  the  baby  griping  pains.  Sweets  are  apt  to  sour  on  the 
mother's  stomach,  and  had  better  be  kept  out  of  the  diet  till  she  is 
quite  well. 

As  to  beverages,  the  regimen  must  vary  according  to  whether  the 
mother  is  nursing  her  child  or  not.  If  she  is,  she  should  have  plenty 
of  fluid  food.  I  order  a  plate  or  a  cupful  of  milk,  tea,  coffee,  choco- 
late, beef  tea,  mutton  or  chicken  broth,  or  oatmeal  or  farina  gruel  to 
be  taken  every  two  hours,  besides  which  she  may  drink  plain  water 
or  mineral  water  ad  libitum.  Beer  increases  the  secretion  of  milk  and 
strengthens  the  nursing  woman,  but  the  writer  has  noticed  that  it 
sometimes  causes  a  diarrhoea  in  the  child,  which  cannot  be  checked 
until  the  tempting  beverage  is  given  up.  If,  on  the  other  hand,  the 
mother  will  not  or  cannot  or  may  not  nurse  her  child,  she  should 
drink  as  little  as  possible.  Her  bowels  should  be  moved  daily  with 
a  saline  aperient,  preferably  sodium  sulphate  or  phosphate,  a  heaping 
teaspoonful  or  more.  I  cover  each  breast  with  a  layer  of  absorbent 
cotton,  moistened  with 

R   Atropina^  sulphatis,  gr.  ij  (12  centigrammes)  ; 
Glycerini,   5ij  (60  grammes). 


THE  CARE  OF  THE  MOTHER.  235 

Outside  of  the  cotton  is  laid  a  piece  of  gutta-percha  tissue  two  inches 
greater  in  diameter  than  the  cotton  pad,  and  outside  of  the  water- 
proof material  comes  the  breast-jacket  presently  to  be  described,  which 
in  this  case  is  put  on  as  tight  as  possible  and  tightened  daily  when  the 
breasts  begin  to  shrink.  The  dressing  remains  undisturbed  until  the 
production  of  milk  ceases,  whicli  takes  eight  or  ten  days. 

As  a  rule,  the  mother  should  nurse  her  child.  It  is  ordained  by 
nature,  and  it  is  better  for  herself  and  her  child.  Suckling  produces 
uterine  contractions,  the  greatest  safeguard  against  infection  and  sub- 
involution. If  she  leaves  this  function  to  another  woman,  the  child 
will  love  the  wet-nurse  more  than  it  will  its  mother,  and  if  she  brings 
it  up  on  a  bottle  the  child  is  rarely  nourished  so  well  and  is  much 
more  liable  to  digestive  disorders.  But  there  are  circumstances 
which  make  it  impossible  or  unadvisable  for  the  mother  to  nurse. 
If  she  has  no  nipples,  or  if  instead  of  protruding  they  form  a  hollow 
under  the  level  of  the  breast,  there  is  nothing  for  the  child  to  take 
hold  of,  and  nursing  becomes  impossible.  Serious  diseases  that  have 
undermined  the  mother's  constitution,  such  as  cancer,  tuberculosis, 
or  serious  cardiac  trouble,  should  be  looked  upon  as  a  barrier  to 
lactation.  This  is  not  the  case  with  syphilis.  The  child,  having  been 
built  up  by  the  mother's  blood,  cannot  be  injured  by  her  milk,  while 
it  is  criminal  to  expose  another  woman  to  infection  from  the  child  by 
nursing  it.  Sometimes  the  mother's  engagements  by  which  she  earns 
her  living  are  such  that  she  cannot  nurse  the  child.  If  for  any  reason 
it  is  known  beforehand  that  the  mother  shall  not  nurse,  then  it  is 
much  better  that  the  milk  be  dried  up  at  once  in  the  manner  described 
above,  for  the  breasts  are  much  more  hkely  to  become  inflamed  if 
lactation  is  begun  and  then  stopped  after  a  short  time. 

If  the  mother  is  to  nurse  her  child,  this  should  be  placed  at  the 
breast  when  the  mother  has  rested  a  little  and  the  baby  has  been 
bathed,  say  about  two  hours  after  delivery.  In  the  beginning  nursing 
is  often  a  little  difficult.  The  child  has  to  learn  to  suck,  and  the 
mother  has  to  adapt  herself  to  it.  She  should  lie  a  little  turned  to 
one  side,  and  have  the  child  placed  parallel  to  herself  at  such  a  height 
that  the  mouth  is  on  a  level  with  the  nipple.  It  is  well  to  seize  the 
child's  sinciput  and  hold  its  mouth  on  to  the  nipple.  It  is  also 
advisable  to  press  a  few  drops  of  the  contents  of  the  breast  into  the 
mouth,  so  that  the  child  gets  the  taste  of  the  fluid.  If  the  nipples  are 
short,  they  may  be  lengthened  by  pulling  on  them  with  the  thumb 
and  two  nearest  fingers,  or  by  applying  to  them  a  breast-pump  with 
rubber  ball  (Fig.  238),  by  which  a  vacuum  is  formed.  The  mother 
must  be  taught  how  to  depress  her  breast,  so  as  to  leave  the  nostrils 
of  the  suckling  free  for  the  entrance  of  air.  The  first  few  days  the 
supply  often  is  so  scant  that  the  child  is  not  satisfied.     Then  it  should 


236 


NORMAL   PUERPERY. 


be  given  slightly  sweetened  boiled  water  with  a  teaspoon,  or,  if  that 
does  not  satisfy  its  craving,  even  boiled  cow's  milk  in  the  proportion 
of  one  part  to  two  may  be  added  to  the  sweetened  water.  In  the 
beginning  both  breasts  will  be  needed,  but  when  the  milk  production 
is  well  established  the  contents  of  one  breast  suffice  often  to  still  the 
hunger  of  the  child,  and  then  the  two  breasts  should  be  used  alter- 
nately. In  the  beginning  tlie  child  should  be  put  to  the  breast  as 
often  as  it  awakes,  but  soon  a  certain  regularity  should  be  estab- 
lished, so  that  the  child  nurses  about  every  three  hours,  even  if  it  be 
necessary  for  that  purpose  to  awake  it.  Also  in  regard  to  sleep  its 
education  should  begin  early.  Some  children  will  sleep  all  the  even- 
ing and  be  awake  all  night,  which  is  very  inconvenient  for  their 
attendants  and  may  seriously  interfere  with  the  mother's  well-being. 
By  nursing  them  and  playing  with  them  in  the  evening  hours,  often  a 


JFiG.  238. 


A  breast-pump. 

good  night's  rest  may  be  gained  for  all  concerned,  only  interrupted 
once  or  twice  by  the  child's  legitimate  want  of  food. 

The  child  should  not  be  allowed  to  play  with  the  nipple  and  fall 
half  asleep  and  wake  up  indefinitely.  Under  these  circumstances  it 
should  be  kept  awake  by  gentle  shaking  and  reminded  to  suck. 

The  nipples  should  be  kept  clean  by  washing  them  with  plain 
lukewarm  water  or  saturated  solution  of  boric  acid  before  and  after 
each  nursing;  but  only  the  softest  material,  such  as  absorbent  cotton^ 
should  be  used  for  this  purpose,  and  the  nipples  should  be  wiped 
dry,  so  as  to  avoid  maceration  of  the  epithelium  and  excoriation. 

When  about  the  fourth  day  the  breasts  swell  and  become  hard  in 
consequence  of  the  plentiful  production  of  milk,  I  surround  the  chest 
by  a  breast-bandage.  In  Maternity  Hospital  we  have  these  ready- 
made,  composed  of  two  layers  of  muslin  sewed  together.  In  private 
practice  I  cut  them  myself  Avith  a  pair  of  scissors.  I  take  a  piece  of 
unbleached  muslin  a  yard  long  and  half  a  yard  wide,  fold  it  in  the 
middle  by  bringing  the  ends  together,  and  cut  out  at  tlie  upper  side  a 


THE   CARE   OF   THE   MOTHER.  237 

quarter  of  a  circle  with  a  radius  of  two  and  one-half  inches  (Fig.  239, 
No.  1).  Next  I  place  the  bandage  around  the  chest  of  the  patient 
and  notice  how  much  the  ends  overlap.  After  having  placed  the  band- 
age on  a  table,  I  make  the  ends  overlap  as  much  as  before  and  cut  out 
on  each  side  a  piece  eight  inches  long  and  two  and  one-half  inches 
wide  when  folded  in  the  middle  (Fig.  239,  No.  2),  the  first  piece  cut 
off  being  used  as  a  pattern  for  the  second.  The  bandage  (Fig.  239, 
No.  3)  is  now  placed  behind  the  back  of  the  patient,  who  is  first  raised 
to  a  half-sitting  posture,  and  then  let  down  again  so  as  to  lie  flat  on 
her  back.  The  flaps  are  brought  under  her  arms  and  up  in  front 
towards  the  shoulders,  and  pinned  together  with  large  safety-pins 
from  below  upward,  while  the  patient  herself  keeps  the  breasts  up- 
ward and  inward  with  her  flat  hands  applied  outside  of  the  bandage. 
When  the  breasts  are  reached,  a  wad  of  cotton  is  placed  between  the 
two  and  the  pinning  continued  until  the  level  of  the  upper  end  of  the 
breasts  is  reached.  Then  each  flap  is  folded  lengthwise  so  as  to  cor- 
respond in  width  to  the  posterior  flaps  between  the  notches  for  the 
neck  and  the  arms,  and  finally  the  anterior  and  the  posterior  flaps 
are  pinned  transversely  together  with  two  small  safety-pins  (Fig.  229, 
p.  202).  By  lifting  and  equally  compressing  the  breasts,  this  bandage 
not  only  affords  great  comfort  to  the  patient  but  is  an  almost  absolute 
protection  against  the  formation  of  that  painful  and  disfiguring  disease, 
a  mammary  abscess.  When  the  breasts  become  soft  again  and 
nursing  is  well  established,  about  the  ninth  day,  this  bandage  may  be 
left  off. 

Before  leaving  this  subject,  I  wish  to  add  a  word  about  the  devel- 
opment and  the  name  of  this  bandage,  which  has  found  its  way  in  more 
or  less  correct  shape,  and  sometimes  under  another  name,  into  many 
books  on  obstetrics  and  nursing.  At  the  earlier  part  of  my  service  at 
Maternity  Hospital  I  was  surprised  at  the  common  occurrence  of 
mammary  abscesses,  which  I  attributed  to  the  way  in  which  sore 
nipples  and  caked  breasts  were  treated.  On  the  1st  of  October,  1882, 
I  introduced  a  radical  change  in  this  respect.  The  use  of  breast- 
pumps,  rubbing  and  kneading,  that  had  flourished  until  then,  was 
totally  discarded,  and  instead  I  ordered  even  compression  by  means 
of  a  bandage  just  broad  enough  to  cover  the  breasts.  To  this  were 
soon  added  two  shoulder-straps,  and,  seeing  the  beneficent  effect  in 
inflammation,  I  used  this  treatment  soon  as  a  preventive  also,  and  in 
the  skilful  hands  of  the  head-nurse.  Miss  Marion  Murphy,  the  three 
pieces  were  blended  into  one,  forming  a  kind  of  sleeveless  waist, 
which,  in  honor  of  the  said  lady,  I  described  under  her  name ;  but 
since  the  underlying  principle  and  the  original  bandage  were  intro- 
duced by  me,  and  since  the  name  has  given  rise  to  the  misunder- 
standing  that  this  jacket   had   the    same    origin   as   the  celebrated 


238 


NORMAL    PUERPERY. 


button  used  in  intestinal  surgery,  I  now  give  it  my  name,  although 
I  thereby  appropriate  something  that  is  an  improvement  on  my 
own  work. 

In  some  women  the  milk  runs  out,  so  that  not  enough  is  left  for 
the  cliild.     Then  it  may  become  necessary  to  give  diluted  cow's  milk 


Fig.  239. 

No.  I 


Z'/ain. 


Win. 


ZVain. 


Sin. 


besides.  In  others  the  milk  gives  out  after  a  few  months,  or  their 
health  suffers  so  much  by  nursing  that  it  has  to  be  discontinued. 
Under  such  circumstances  the  child  must  connnonly  be  nourished 
artificially,  as  in  most  cases  it  is  difficult  to  find  a  wet-nurse  willing  to 
enter  on  ser\dce  at  so  late  a  date.     If  there  is  milk  enough,  but  the 


THE    CARE    OF    THE    MOTHER. 


239 


mother  does  not  want  to  be  the  only  source  of  supply,  she  may  be 
allowed  to  combme  her  own  nursing  with  the  administration  of  a 
couple  of  bottles  of  dilute  cow's  milk.  Many  prefer  such  an  arrange- 
ment for  the  night.  If  there  is  breast-milk  enough,  the  child  should 
live  on  that  exclusively  for  the  first  nine  months  of  its  life.  Lactation 
may  without  harm  be  pushed  a  few  months  further,  but  it  must  be 
looked  upon  as  an  abuse  when  women  of  the  lower  classes,  in  order 


5  In. 

1 

No.3. 

5in. 

6 '/2m. 

4-111. 

'  4-in. 

6 'A  in. 

U 

\j 

36  in. 

Garrigues's  breast-bandage. 

to  avoid  a  new  impregnation,  continue  nursing  during  the  second 
year.  This  constitutes  an  unnatural  drain  upon  the  maternal  organism 
which  may  have  bad  consequences. 

When  the  time  for  weaning  the  child  has  come,  it  should  be  done 
quite  gradually  in  the  course  of  eight  or  ten  days  by  substituting 
every  day  one  more  artificial  meal  for  each  suckling.  The  transition 
is  done  best  to  slightly  diluted  cow's  milk.     Cow's  milk,  undiluted, 


240 


NORMAL   PUERPERY. 


Fig   240 


should  continue  to  be  the  staple  food  during  the  second  year,  but, 
besides  that,  the  child  may  have  zwieback  soaked  in  milk,  an  egg, 
chicken-breast,  or  very  finely  cut  rare  roast  beef  or  steak. 

Returning  to  the  lying-in  period,  the  perineal  bandage  should  be 
renew^ed  three  times  a  day,  and  also  after  each  micturition  and  defe- 
cation. Morning  and  evening  a  douche-pan  should  be  placed  under 
the  patient,  and  the  external  genitals  with  the  nearest  surrounding 
parts  should  be  syringed  with  lysol  (two  teaspoonfuls  to  a  quart  of 
water),  but  the  nurse  should  be  strictly  forbidden  to  touch  the  patient. 
If  some  blood-clot  adheres  to  the  hairs,  she  may  wipe  it  off  with 
absorbent  cotton  dipped  in  the  lysol  water.  After  eight  days  the 
medicated  perineal  pad  may  be  omitted  and  a  common  sanitas  pad 
or  diaper  used  instead. 

The  abdominal  binder  should  be  tightened  once  every  day,  and 
when  soiled  it  should  be  replaced  by  another.     When  the  woman 

gets  out  of  bed  this  binder  be- 
comes inconvenient,  but  she 
should  for  a  couple  of  months 
use  a  well-fitting  abdominal 
supporter.  The  writer  has 
found  that  of  Teufel  (Fig. 
240)  particularly  well  adapted 
to  obstetric  cases,  both  before 
and  after  delivery. 

As  a  rule,  some  mild 
aperient  is  needed  to  move 
the  bowels.  An  enema  of 
soapsuds  may  be  given  on  the  third  day.  Many  women  like  the  com- 
pound liquorice  powder  of  the  pharmacopoeia,  a  heaping  teaspoonful 
of  which,  stirred  with  a  little  water  and  taken  in  the  evening,  as  a 
rule,  is  followed  by  a  good  movement  next  morning.  For  those  who 
prefer  a  pill  I  usually  prescribe  the  following  combination : 

R    Podophylli  resinse,  gr.  iv  (24  centigrammes)  ; 

Extr.  belladonnae  alcoholic!,  gr.  ij  (12  centigrammes)  ; 

Extr.  gentianae  compositi,  q.  s. 
Ft.  pil.  no.  viii.     Sig. — A  pill  once  or  twice  a  day. 


Teufel's  abdominal  supporter. 


Before  leaving  the  house  I  prescribe  an  ounce  of  fluid  extract  of 
ergot,  of  which  a  teaspoonful  is  to  be  given  three  times  a  day.  It 
helps  contraction,  and  thus  indirectly  becomes  an  antiseptic  and  may 
also  combat  after-pains.  I  leave  likewise  a  prescription  for  Magendie's 
solution  of  morphine,  six  drops  to  be  given  if  the  woman  complains 
of  after-pains,  and  repeated,  if  needed,  four  times  a  day. 


THE    CARE    OF    THE    MOTHER.  241 

Quiet  should  reign  in  the  lying-in  room.  With  the  exception  of 
the  very  nearest, — for  instance,  the  husband  and  the  mother  of  the 
puerpera, — visitors  should  be  kept  away  until  she  has  been  out  of  bed 
for  a  few  days,  and  even  then  admitted  only  in  small  numbers  and 
one  at  a  time.  All  news  apt  to  cause  grief  or  anxiety  should  be  kept 
back  from  her  till  she  has  regained  more  mental  and  physical  strength. 
As  a  pastime,  light  literature  may  be  indulged  in  after  a  few  days, 
or  the  puerpera  may  do  some  light  hand-work,  such  as  knitting  or 
crocheting. 

A  very  important  question,  and  one  upon  which  the  views  of 
authorities  vary  considerably,  is,  How  long  should  a  woman  stay  in 
bed  after  delivery?  In  some  institutions  they  do  not  keep  normal 
puerperse  over  five  days.  In  most  it  is  the  routine  practice  to  keep 
them  in  bed  for  nine  days,  and  that  this  is  the  proper  time  is  a  very 
common  idea  among  midwives  and  lay  women  in  all  civilized  coun- 
tries ;  and  in  this  country,  when  a  doctor  is  engaged  for  a  "  confme- 
rnent,"  the  understanding  is  that  the  remuneration  agreed  upon 
covers  the  day  upon  which  labor  begins  and  a  visit  on  each  of  the 
following  nine  days.  This  may  in  so  far  be  justifiable  as  in  most 
cases  involution  has  then  proceeded  sufficiently  that  the  woman  may 
leave  her  bed  without  harm,  and  in  public  institutions  some  rule  is 
necessary  for  the  regular  occupation  of  the  wards.  In  private  prac- 
tice the  time  of  getting  up  should  not  be  regulated  by  days,  but  by 
the  condition  of  the  woman. ^  We  have  seen  above  how  slow  the 
uterus  is  in  regaining  its  normal  size  and  weight.  Special  investiga- 
tions with  curved  and  straight  sounds  have  been  made,  in  order  to 
find  directly  the  influence  of  the  erect  posture  on  the  shape  and 
place  of  the  puerperal  uterus,  and  it  was  found  that  it  increases  the 
anteflexion  and  anteversion  and  the  protrusion  of  the  abdomen,  while 
the  uterus  as  a  whole  is  pushed  backward. 

While  gravitation  tends  to  combat  these  conditions  when  the 
woman  lies  on  her  back,  in  the  erect  posture  it  works  under  the  very 
best  angle — that  is  to  say,  perpendicularly  on  the  long  axis  of  the 
uterus — to  make  them  worse.  It  gets  a  good  purchase  by  taking 
hold  of  the  enlarged  body  which  forms  the  long  arm  of  a  lever  placed 
horizontally,  while  the  cervix  represents  the  short  arm  of  the  same 
placed  almost  perpendicularly.  We  must,  furthermore,  remember 
that  the  uterus  and  all  the  parts  of  the  body  that  serve  to  support  it 
are  soft,  flexible,  and  yielding  after  childbirth.  From  these  premises 
I  infer  that  the  upright  and  sitting  postures  should  be  avoided  until 
involution  has  progressed  so  far  that  the  uterus  has  receded  from  the 
anterior  abdominal  wall  and  returned  to  the  pelvic  cavity,  where  it 

^  Garrigues,  "Rest  after  Delivery,"  Ainer.  Jour.  Obst.,  October,  1880,  vol. 
xiii.,  No.  4. 

16 


242  NORMAL    PUERPERY. 

is  much  better  protected.  This  is  easily  ascertained  by  external  pal- 
pation. If  the  fundus  is  still  above  the  pelvic  brim  when  the  physician 
chscontinues  his  visits,  he  should,  among  other  good  advice  he  gives 
in  taking  his  departure,  tell  the  patient  to  stay  in  bed  for  so  many 
more  days  as  he  deems  it  will  take  before  the  uterus  has  sunk  down 
behind  the  symphysis  pubis. 

If  the  patient  w^ent  to  another  extreme  and  stayed  three  or  four 
weeks  or  longer  in  the  recumbent  position,  there  would  be  danger  of 
the  normal  anteflexion  and  anteversion  turning  into  the  always  abnor- 
mal retroflexion  and  retroversion. 

Whenever  the  patient  is  allowed  to  get  up,  it  should  be  done 
cautiously.  She  is  weak  from  lying  in  bed,  from  suffering,  from  loss 
of  blood,  lochial  discharge,  and  milk,  and  in  consequence  of  a  more 
or  less  restricted  diet.  She  is,  therefore,  apt  to  faint.  I  like  to  let 
her  first  be  helped  over  on  a  lounge,  upon  which  her  head  is  raised  to 
a  higher  position  while  the  body  still  remains  horizontal.  The  next 
day  she  may  sit  on  an  easy-chair,  with  the  feet  down  for  an  hour. 
The  following  day  she  will  stay  up  two  or  three  hours,  and  thus  grad- 
ually return  to  the  common  way  of  living.  She  should  not  walk  up 
and  down  stairs  before  the  end  of  three  weeks,  and  not  go  out  before 
the  end  of  a  month.  During  a  similar  length  of  time  she  should  not 
pick  up  anything  from  the  floor,  such  a  sudden  movement  having 
occasionally  caused  an  embolus  to  be  carried  from  a  uterine  sinus  and 
lodged  in  the  brain,  resulting  in  apoplexy  and  death. 

Marital  relations  ought  not  to  be  resumed  before  the  genitals  in 
the  main  have  returned  to  their  normal  condition, — say  six  or  eight 
weeks  after  childbirth.  That  conception  is  possible  much  sooner  is 
proved  by  a  case  published  by  a  German  physician,  in  which  coition 
resulting  in  impregnation  took  place  four  days  after  delivery.  But 
the  poor  woman  should  be  given  a  rest  before  she  is  called  upon  to 
develop  another  foetus  in  her  body. 

The  writer  is  aware  that  few  are  so  situated  that  they  can  follow 
all  these  rules.  The  poor  servant-girl  leaves  the  hospital  within  a 
fortnight,  and  either  must  do  general  housework  or  take  a  position  as 
a  wet-nurse,  in  which  she  is  expected  to  give  every  attention  to  the 
child  for  whose  benefit  she  is  engaged,  and  not  to  take  too  much  care 
of  herself.  The  poor  married  woman  must  attend  to  her  household 
duties.  But  that  is  no  reason  why  those  who  can  afford  it  should  not 
have  the  best  of  care,  based  on  scientific  principles.  Long  experience 
in  hospital  and  dispensary  services  has  taught  the  writer  how  much 
more  commonly  all  kinds  of  gynaecological  diseases,  even  including 
cancer  of  the  uterus,  are  found  as  sequels  of  childbirth  among  the 
poor  than  among  the  wealthy. 


SIGNS    OF   THE    PUERPERAL   STATE.  243 

CHAPTER    III. 
SIGNS    OF   THE   PUERPERAL   STATE. 

In  cases  of  clandestine  childbirth,  the  medical  expert  is  sometimes 
asked  whether  a  woman  has  recently  borne  a  child.  During  the  first 
two  weeks  this  question  can,  as  a  rule,  easily  be  answered,  while  after 
that  time  it  becomes  more  difficult.  The  signs  to  which  the  physician 
should  pay  special  attention  are  a  gaping  vulva ;  the  softness  and  lack 
of  elasticity  of  the  labia  majora ;  tears  on  their  inside,  at  the  fourchette, 
of  the  labia  minora,  or  the  entrance  of  the  vagina  ;  a  gangrenous  con- 
dition of  the  hymen,  or  parts  of  it  being  swollen,  torn,  abraded,  or 
covered  with  granulations  ;  the  lack  of  elasticity  and  the  presence  of 
lesions  of  the  vagina ;  a  long,  soft,  and  torn  cervix ;  the  open  os  inter- 
num ;  the  enlarged,  anteflexed  uterus ;  a  rough  placental  site  ;  the 
lochial  discharge ;  purple-colored  abdominal  streaks  ;  the  laxity  of  the 
abdominal  wall  •,  the  presence  of  a  linea  fusca ;  milk  in  the  breasts ; 
and  the  dark  color  and  large  size  of  the  areola. 

Some  of  these  signs  allow  us  even  to  say  more  or  less  definitely 
how  many  days  have  elapsed  since  the  child  was  born.  Thus,  colos- 
trum is  rarely  found  after  the  first  four  days ;  all  the  wounds  will 
granulate  within  eight  days  ;  the  internal  os  becomes  impermeable  for 
the  finger  in  ten  or  twelve  days. 

Permanent  Changes  caused  by  Childbirth. — As  a  rule,  it  can  also 
be  diagnosticated  whether  or  not  a  woman  at  a  more  remote  period 
of  her  life  has  borne  a  child.  In  most  cases  the  vulva  is  more  or  less 
open  in  the  parous  woman.  The  fourchette  is  often  torn  and  the  seat 
of  white  cicatricial  tissue.  The  vaginal  entrance  commonly  is  wider 
and  shows  cicatrices.  The  hymen  is  not  only  torn,  but  has  sustained 
a  loss  of  substance,  reducing  it  to  carunculse  myrtiformes.  The 
vagina  is  wider  and  more  smooth.  The  cervix,  as  a  rule,  shows 
small  nicks,  if  it  is  not  outright  torn.  The  external  os  forms  a  trans- 
verse slit.  The  abdominal  wall  is  likely  to  be  flaccid  and  show  white, 
more  or  less  perpendicular  cicatrices  with  fine  transverse  lines.  The 
breasts  are  more  hanging,  the  areola  darker  and  larger,  and  some- 
times there  may  be  found  one  or  more  cicatrices  after  a  mammary 
abscess.  But  occasionally  even  the  most  experienced  observer  may 
be  in  doubt  whether  he  has  to  deal  with  a  nullipara  or  a  woman  who 
has  had  a  child. 


244  NORMAL    PUERPERY. 

CHAPTER    IV. 
THE    COXDITIOX    OF   THE    CHILD. 

After  birth  the  temperature  of  the  child  sinks  rapidly  to  95°  F., 
and  then  rises  gradually  until  after  twenty-four  hours  it  reaches  the 
normal  temperature  of  grown-up  persons.  After  that  its  temperature 
averages  97J°  in  the  morning  and  98  J°  in  the  evening. 

The  change  in  circulation  has  already  been  described  in  connection 
with  the  two  fetal  systems  of  circulation  (page  47).  The  irritative 
cause  that  makes  the  umbilical  arteries  contract  and  stop  pulsatmg  is 
cold,  which  is  proved  by  plunging  the  child,  after  the  circulation  in  the 
umbilical  cord  has  ceased,  into  a  warm  bath,  when  the  arteries  begin 
again  to  pulsate.  That  is  why  the  ligature  of  the  navel-string  should 
be  examined  and,  if  necessary,  tightened  before  bathing  the  child. 

The  respiration  is  frequent  and  superficial.  The  child  breathes  up 
to  50  times  a  minute,  and  the  amount  of  expired  air  is  forty-five 
cuJDic  centimetres.  The  air  enters  very  gradually  into  the  different 
lobuli  of  the  lungs,  which  remain  so  atelectatic  that  only  very  small 
portions  of  them  will  float  in  water,  while  larger  invariably  fall  to  the 
bottom  (Ahlfeld),  which  has  an  important  medico-legal  bearing.  This 
test,  upon  which  much  stress  is  laid  in  deciding  the  question  whether 
a  child  breathed  before  death  or  not,  is  therefore  reliable  only  when 
it  is  positive, — ^that  is  to  say,  if  parts  of  the  lung  float,  it  proves  that 
the  child  has  respired  before  dymg ;  but  the  sinking  of  the  pieces  does 
not  prove  that  it  has  not  breathed. 

The  respiration  has  often  a  stertorous  sound,  which  is  probably 
due  to  aspired  mucus  or  liquor  anmii. 

The  pulse  of  the  new-born  child  beats  about  twice  as  frequently 
as  that  of  an  adult.  It  averages  137  in  a  minute  during  the  first  two 
months,  128  from  the  tliird  to  the  sixth  month,  120  jfrom  the  seventh 
month  to  the  end  of  the  year,  and  118  up  to  the  twenty-first  month. 
Its  frequency  varies  much  under  the  influence  of  movements,  crying, 
and  external  impressions.  It  is  less  frequent  in  strong  than  in  puny 
children.  In  healthy  children  it  is  strong  and  regular.  It  cannot  be 
taken  at  the  wrist,  however,  but  may  be  counted  at  the  heart. 

The  first  few  days  a  lively  desquamation  takes  place  on  the  skin. 
At  first  the  child  has  a  reddish  color,  but  this  disappears  in  a  few  days. 
The  head  of  the  new-born  child  is  congested.  At  the  place  that  cor- 
responds to  the  vagina  there  is  some  swelling,  due  to  oedema,  and 
even  small  extravasations  of  blood  under  the  skin  or  under  the  galea 
aponeurotica,  but  this  condition  disappears  within  twenty-four  hours. 
The  conjunctiva  is  injected,  and  shows  sometimes  suggillations,  which 
soon  are  reabsorbed. 


THE    COXDITIOX    OF    THE    ('Hn.D.  245 

Fceces. — Shortly  after  the  birth  of  the  child  the  meconium  is  ex- 
pelled from  the  rectum.  This  dark-green,  almost  black,  tarry  mass  is 
followed  by  brown  fecal  matter,  which  becomes  lighter  and  lighter  in 
color  until  about  the  end  of  the  first  week  it  is  of  light-yellow  color. 
It  is  largely  composed  of  bacterium  coli  commune,  which  probably 
plays  the  role  of  a  ferment  to  accomphsh  the  decomposition  of  the 
milk  while  the  salivary  glands  are  yet  little  developed.  The  glyco- 
genic ferment  is  found  only  in  small  quantity  in  the  parotid,  and  is 
absent  from  the  other  buccal  glands  and  the  pancreas.  During  the 
first  week  starchy  substances  are,  therefore,  an  inappropriate  food, 
which  only  fills  the  intestine  to  no  purpose.  The  odor  of  the  infan- 
tile faeces  is  nauseous  and  acid,  but  does  not  suggest  any  putrefaction. 

At  the  birth  of  the  child  the  bladder  contains  only  about  two 
fluidrachms  of  urine,  and  its  secretion  is  slow.  Quite  frequently  the 
urine  is  not  evacuated  before  the  second  day.  From  the  second  to 
the  tenth  day,  till  there  is  a  freer  flow  of  fluid  from  the  kidneys,  these 
are  often  the  seat  of  the  so-called  urinary  infarction,  a  deposit  of 
orange-colored  uric  acid  in  the  straight  canals,  whence  it  is  carried  out 
through  the  ureter,  bladder,  and  urethra,  and  stains  the  diaper.  The 
urine  is  light  straw-colored,  acid,  and  has  a  specific  gravity  of  1005- 
1007.  It  contains  little  urea,  uric  acid,  and  phosphates,  but  some 
albumin  and  sugar. 

During  the  first  three  or  four  days  the  child  loses  in  weight,  the 
total  loss  amounting  to  seven  or  eight  ounces,  ^vhich  is  accounted  for 
by  the  expulsion  of  the  meconium,  the  urinary  secretion,  and  per- 
spiration. By  the  ninth  or  tenth  day  this  loss  has  been  repaired,  and 
the  child  has  the  same  weight  as  at  birth.  From  that  time  on  it  grows 
steadily  in  weight  and  size.  At  the  end  of  four  months  its  weight  is 
doubled,  and  at  the  end  of  a  year  trebled.  During  the  first  four 
months  the  child  gains  on  an  average  an  ounce  a  day,  fi:-om  the  fifth 
month  only  half  an  ounce  or  less,  but  in  the  second  year,  when  more 
substantial  food  is  given,  the  weight  increases  again  more  rapidly,  so 
that  at  the  end  of  sixteen  months  it  is  four  times  that  at  birth. 

The  child  sucks  by  adapting  its  hollowed  tongue  to  the  lower  half 
of  the  nipple,  closing  the  lips  all  around  it,  and  producing  a  vacuum 
by  means  of  inspiration.  A  special  centre  for  this  act  has  been  found 
in  the  medulla  oblongata. 

In  the  beginning  the  child  sleeps  much,  sometimes  four  or  five 
hours  at  a  stretch,  and  its  sleep  is  interrupted  only  by  sucking.  Later 
it  lies  more  and  more  awake,  and  gradually  develops  an  interest  in  its 
surroundings,  especially  moving  objects.  It  has  all  its  senses,  touch 
and  taste  being  particularly  keen,  sight  and  hearing  soon  become  dis- 
tincter,  whereas  it  seems  that  smell  is  slower  in  its  development. 

The  umbilical  cord  dries  up  and  gradually  becomes  detached  from 


246  NORMAL   PUERPERY. 

the  abdomen.  In  most  cases  it  falls  off  on  the  fifth  day,  leaving  a 
circular  granulating  surface,  which  heals  in  the  course  of  twelve  to 
fifteen  days,  and  forms  an  uneven,  somewhat  retracted  cicatrice. 

The  red  color  of  the  skin  does  not  always  go  over  to  the  normal 
yellowish-pink  color.  Quite  frequently — in  seventy-five  per  cent,  of 
children — it  is  followed  by  a  decided  yellow  color,  implicating  not 
only  the  skin,  but  also  the  mucous  membranes,  especially  the  con- 
junctivae, and  constituting  a  true  jaundice,  icterus  neonatorum.  Of 
the  many  theories  advanced  to  explain  this  phenomenon,  the  most 
plausible  seems  to  me  to  be  that  the  pigment  comes  from  destroyed 
red  blood-corpuscles,  and  that  the  pressure  in  the  umbihcal  vein 
diminishes  so  much  after  the  birth  of  the  child  that  the  bile  enters 
the  blood.  The  fact  is  that  analytical  chemistry  has  proved  a  surplus 
of  haemoglobin  in  the  blood  of  the  new-born.  This  icterus  bemg  so 
common,  and  the  children  affected  by  it  appearing  to  be  in  good 
health,  it  cannot  be  looked  upon  as  a  disease,  but  as  part  of  the 
normal  changes  taking  place  in  the  child  after  birth.  It  lasts  three  or 
four  days,  and  disappears  without  any  medication. 


CHAPTER    V. 
THE    CARE   OF   THE    CHILD. 

A  NEW-BORN  infant  needs  little  air,  but  much  warmth.  Cradles 
have  mostly  been  given  up.  The  child  should  first  be  laid  in  a  basket 
with  soft  pillows  under  its  body  and  head,  and  should  be  covered  with 
a  woollen  blanket  or  even  a  light  feather-bed.  This  basket  should  not 
be  so  large  that  it  cannot  easily  be  carried  from  one  place  to  another. 
The  bedclothes  may  be  protected  against  wetting  by  a  rubber  sheet, 
but  the  infant  should  not  have  any  clothes  of  such  material,  as  they 
interfere  with  the  free  evaporation  and  cause  chafing.  When  the 
child  grows  out  of  its  basket,  it  should  have  a  crib.  It  should  lie  by 
itself  and  not  in  the  mother  s  bed,  in  order  to  avoid  the  constant 
inhalation  of  the  air  vitiated  by  respiration  and  evaporation  from  the 
maternal  body,  and  the  still  greater  danger  of  the  mother  in  her  sleep 
rolling  over  it  and  smothering  it.  It  should  be  lightly  dressed,  as 
described  above.  No  kind  of  swaddling-bands  should  interfere  with 
the  free  movements  of  its  limbs.  Nor  is  it  necessary  to  carry  it  on  a 
mattress  in  the  idea  that  its  vertebral  column  needs  a  special  support. 

If  cradles  have  been  abandoned  as  useless,  and  perhaps  even 
injurious  to  the  nervous  system,  it  is  irrational  to  place  the  child  in  a 
rocking-chair  and  rock  that,  which  has  the  same  effect  as  a  cradle. 
Upon  the  whole,  the  greatest  care  should  be  observed  to  avoid  foster- 


THE   CARE    OF   THE   CHILD.  247 

ing  habits  in  the  child  which  are  either  injurious  to  itself  or  burden- 
some to  its  attendants.  The  child's  education  should  begin  at  birth, 
and  the  first  aim  should  be  to  accustom  it  to  regularity  and  good 
habits.  It  is  wonderful  to  see  how  soon  habits  are  acquired  by  the 
new-born  infant,  and  if  they  are  not  led  in  a  proper  direction  the 
child  soon  becomes  a  tyrant  who  exhausts  the  strength  of  its  mother 
or  nurse  and  disturbs  the  whole  household.  The  more  the  child  is 
left  alone  the  better  it  is  for  all,  which  by  no  means  implies  neglect  of 
proper  care.  If  the  child  has  not  urinated  when  I  see  it  the  day  after 
•its  birth,  I  introduce  a  silver  probe  smeared  with  a  little  vaseline, 
which  invariably  is  followed  by  a  rush  of  urme.  Likewise,  if  it  has 
not  passed  meconium,  which  is  much  rarer,  I  introduce  the  little  finger 
well  anointed  through  the  anus,  which,  if  there  is  no  organic  mal- 
formation, is  followed  by  the  desu-ed  effect.  The  cause  of  these 
retentions  is  only  an  agglutination  of  the  epithelium  of  the  canals 
concerned,  just  as  two  leaves  in  a  new  book  may  stick  together. 
Once  separated,  the  epithelial  layers  remain  so,  without  giving  rise  to 
any  retention. 

The  child  should  be  bathed  morning  and  evening  in  a  bath-tub 
large  enough  to  permit  free  movements  of  its  limbs.  The  tempera- 
ture of  the  water  should  the  first  few  weeks  be  about  98°  F.,  but 
after  the  first  month  it  is  well  gradually  to  make  it  less  warm,  until 
88°  F.  are  reached.  Cold  baths  cause  too  great  disturbance  in  the 
economy  of  the  infant.  The  cold  frightens  it,  and  the  reaction  is  too 
stimulating  for  it. 

When  the  infant  is  taken  up  every  three  hours,  its  diaper  should 
be  changed.  If  it  is  soiled,  the  dirt  should  be  wiped  off  and  the 
bottom  and  the  genitals  washed  with  lukewarm  water,  but  after  wash- 
ing these  parts  they  should  not  be  wiped,  in  order  to  avoid  excoria- 
tion. Soft  linen  or  muslin  should  only  be  gently  pressed  against  the 
skin,  so  as  to  soak  up  the  moisture.  When  dry,  the  parts  are  dusted 
with  some  fine  powder,  such  as  talcum. 

The  absorbent  cotton  surrounding  the  navel-string  comes  off  in 
the  bath,  and  is  then  renewed.  After  the  cord  has  fallen  off  a  fine 
piece  of  linen  or  muslin  smeared  with  white  vaseline  may  be  placed 
on  the  granulating  surface  until  it  is  healed. 

The  most  important  question  is  how  to  feed  the  child.  We  have 
already  entered  on  this  subject  in  speaking  of  the  care  to  be  given  to 
the  mother,  and  there  said  that  with  few  exceptions  a  mother  should 
give  her  child  suck.  Even  if  in  consequence  of  hemorrhage  she  is 
temporarily  weak,  she  will  soon  recover,  so  that  her  feebleness  need 
not  preclude  her  nursing  her  child.  We  have  also  seen  that  nursing 
should  be  done  at  regular  intervals,  and  great  cleanliness  observed  in 
regard  to  the  nipple. 


248  NORMAL   PUERPERY. 

How  much  a  child  drinks  can  only  be  found  out  by  weighing  it 
before  and  after  each  meal.  This  has  been  done  by  different  obstetri- 
cians with  somewhat  varying  results.  During  the  first  month  the  child 
takes  about  twenty-one  ounces  daily  ;  during  the  second,  about  twenty- 
four  ounces ;  during  the  third,  about  twenty-eight  ounces.;  and  from 
the  fourth  to  the  ninth,  about  thirty-two  ounces. 

When  the  mother  has  a  sufficient  supply  of  milk,  the  child  needs 
from  fifteen  to  twenty  minutes  to  satisfy  its  hunger. 

If  the  mother  cannot  nurse  her  baby,  the  best  substitute  from  a 
purely  physical  stand-point  is  a  vet-nurse,  because  her  milk  has  practi- 
cally the  same  composition,  and  all  the  troubles  of  artificial  feeding 
are  avoided.  Sometimes  the  nursling  may  even  be  better  off  with  a 
strong,  healthy  wet-nurse  than  if  he  were  nursed  by  the  product  of 
the  breasts  of  an  anaemic,  nervous  mother.  But  in  general  there  are 
many  objections  to  a  wet-nurse.  If  a  married  woman,  without  being 
forced  to  it,  deliberately  deprives  her  own  offspring  of  her  milk  in 
order  to  sell  it  to  another  woman,  who  can  afford  to  pay  her  well  for 
it,  she  shows  deficiency  in  the  strongest  of  instincts — the  mother's 
love  for  her  offspring.  If  the  nurse  is  unmarried,  she  usually  owes 
her  condition  to  unmoral  or  immodest  impulses,  which  we  would 
dread  to  see  pass  over  to  our  child  in  consequence  of  having  imbibed 
her  milk.  All  wet-nurses,  married  or  unmarried,  feeling  their  own 
importance,  are  apt  to  become  selfish,  exacting,  and  imperious,  which 
gives  rise  to  conflict  with  other  domestics  or  even  with  members  of 
the  family,  and  disturbs  the  peace  of  the  household.  The  child,  like 
another  animal,  concentrates  its  love  on  the  person  that  feeds  it,  so 
that  there  arises  a  feeling  of  estrangement  from  its  mother.  In  New 
York  wet-nurses  are  also  so  expensive  that  few  can  afford  to  employ 
them. 

In  the  choice  of  a  wet-nurse  the  physician  must  first  of  all  ascer- 
tain that  she  is  healthy,  and  especially  that  she  is  not  tainted  with 
syphilis  or  tuberculosis.  He  should,  therefore,  inspect  as  large  a  part 
of  her  body  as  practicable,  paying  particular  attention  to  cutaneous 
eruptions,  alopecia,  swollen  glands  at  the  neck,  above  the  elbows,  and 
at  the  groins.  The  throat  should  be  examined  for  mucous  patches, 
and,  if  feasible,  also  the  anus  and  genitals  ;  but  most  wet-nurses  refuse 
such  searching  examination.  Under  all  circumstances  he  must  care- 
fully examine  her  lungs,  using  both  percussion  and  auscultation. 

Having  found  her  healthy,  he  should  turn  his  attention  to  her 
breasts.  The  mammary  glands  should  be  well  developed.  She 
should  have  good  nipples.  When  compressed,  a  breast  should  spurt 
the  milk  in  a  jet.  He  should  place  a  drop  under  the  microscope, 
and  ascertain  that  the  field  is  full  of  closely-packed  fat  globules  of  an 
approximately  even  size.     He  may  even  collect  her  milk  ui  a  test- 


THE    CARE    OF    THE    CHILD.-  249 

tube,  in  which,  upon  standing,  there  should  be  not  less  than  ten  per 
cent,  of  cream.  He  should  insist  on  seeing  her  child,  in  order  to 
ascertain  that  it  is  well  nourished  and  shows  no  sign  of  hereditary 
syphilis.  Everything  else  being  ecjual,  he  should  prefer  a  person 
between  twenty  and  thirty  years  of  age.  He  should  not  overlook 
signs  of  habitual  drunkenness,  irritability  of  character,  uncleanliness 
of  person,  or  slovenliness  of  attire. 

If  the  mother  cannot  nurse  her  child  and  no  wet-nurse  can  be 
obtained,  we  are  reduced  to  artificial  feeding.  Tlie  milk  of  the  ass 
and  the  mare  is  nearest  to  w^oman's  milk  in  composition,  but  not 
easily  accessible.  Goat's  milk  is  too  fat,  and  offers  no  advantage  over 
cowl's  milk.  We  are,  then,  as  a  rule,  compelled  to  use  cow's  milk, 
which  is  rather  different  from  woman's  milk,  and  ought,  therefore,  to 
be  modified.  It  contains  more  casein,  and  often  more  fat,  and,  on 
the  other  hand,  less  sugar.  The  casein  forms  larger  coagula,  and  is, 
therefore,  less  easy  to  digest.  In  large  cities  tliere  are  establishments 
where  cow's  milk  is  changed  according  to  prescription,  but  this  prod- 
uct being  necessarily  expensive,  it  is  only  accessible  to  few,  and  the 
large  majority  must  modify  their  cow's  milk  at  home  as  best  they  can. 

Cow's  milk  should  be  diluted  with  water  and  sweetened,  and,  in 
order  to  prevent  it  from  getting  sour,  it  should  be  boiled,  to  which 
time-honored  rules,  since  the  introduction  of  bacteriology,  has  been 
added  the  demand  that  it  should  be  sterilized, — that  is,  that  all 
microbes  in  it  should  be  killed.  Perhaps  the  last  is  not  so  important 
as  may  appear  at  the  first  glance.  Bacteriology  itself  having  taught 
us  that  even  mother's  milk  as  it  flow^s  from  the  breast  often  contains 
saprophytes,  staphylococci,  and  even  streptococci,  no  means  having 
been  indicated  for  sterilizing  that,  and  experience  having  shown  since 
time  immemorial  that  a  child  thrives  better  at  the  human  breast  than 
on  any  other  kind  of  food,  it  may  be  c{uestioned  whether  the  bacteria 
of  cowl's  milk  are  any  more  deleterious  to  the  infant.  But  this  sterili- 
zation having  been  made  very  simple  and  practical  by  the  invention 
of  Soxhlet,  it  is  easy  to  obtain  sterile  milk.  His  apparatus  (Fig.  241) 
consists  of  a  metal  frame  with  seven  holes,  in  each  of  which  is  placed 
a  bottle  filled  with  the  modified  cow-'s  milk.  A  similar  apparatus  has 
been  constructed  here  in  New  York  by  Dr.  A.  Seibert,  and  is  sold  in 
the  drug  stores.  Each  bottle  has  a  rubber  stopper,  which  is  put  on 
loosely  so  as  to  allow  the  air  to  escape.  The  frame  with  the  filled 
bottles  is  placed  in  a  kettle  with  water.  After  boiling  five  minutes 
the  stoppers  are  pushed  dow^n  into  the  necks  of  the  bottles,  and  the 
closed  bottles  boiled  for  forty  minutes  longer.  Then  the  frame  is 
removed  from  the  bain-marie  and  kept  in  a  cool  place,  preferably  an 
ice-box.  When  the  child  is  to  be  fed,  one  of  the  bottles  is  warmed 
slightly,  as  cold  food  causes  stomach-ache.     It  should  have  a  temper- 


250 


NORMAL   PUERPERY. 


ature  of  about  95°  F.,  which  practically  may  be  ascertained  by  press- 
ing the  bottle  against  one's  cheek,  when  it  should  feel  neither  hot  nor 
cold.  As  will  be  seen,  all  the  food  for  the  day  is  prepared  at  once, 
and  only  so  much  warmed  as  is  needed  for  a  meal. 

By  the  prolonged  boiling  the  casein  in  the  milk  forms,  however, 
coagula  hard  to  digest ;  and  some  prefer,  therefore,  to  expose  it  to  a 
temperature  of  only  from  140°  to  160°  F.  for  a  similar  length  of 
time,  which  is  called  pasteurization. 

Recently  two  prominent  pgediatrists  of  New  York  have,  however, 
raised  their  voices  against  both  sterilized  and  pasteurized  milk,  declar- 
ing that  by  exposure  to  heat  the  milk  becomes  a  bad  nourishment 
and  gives  rise  to  rickets  and  scurvy.     On  the  other  hand,  the  Rocke- 

FiG.  241. 


Soxhlet's  sterilizer. 


feller  Institute  reports  that  much  of  the  milk  brought  to  New  York  is 
overfilled  with  bacteria,  and  often  contains  the  germs  of  typhoid  fever, 
diphtheria,  and  other  dangerous  diseases.  After  all,  it  may,  therefore, 
be  the  best  to  come  back  to  what  our  mothers  and  grandmothers  did, 
and  just  boil  the  milk  for  a  few  minutes.  At  the  same  time  every 
effort  should  be  made  to  instruct  the  farmers  about  the  proper  care 
of  cows  and  the  manipulation  of  milk. 

A  certain  number  of  microbes  is  unavoidable.  A  leading  dairy- 
man has  informed  me  that  we  must  not  expect  to  have  milk  in  New 
York  that  contains  less  than  fifteen  thousand  bacteria  in  each  cubic 
centimetre.  But  often  this  number  is  doubled,  and,  as  stated,  dan- 
gerous pathogenic  microbes  are  found  among  them. 

During  the  first  month  cow's  milk  should  be  mixed  with  twice  as 
much  water,  and  one-half  of  a  teaspoonfLd  of  milk  sugar  should  be 
added  to  each  bottle.     During  the  second  month  equal  parts  of  milk 


THE    CARE   OF   THE    CHILD. 


251 


and  water  may  be  given  ;  during  the  third  and  fourth,  two-thirds  of 
milk,  then  three-fourths,  and  as  soon  as  the  child  can  digest  it  the 
milk  should  be  given  undiluted.  Instead  of  plain  water  it  is  better  to 
use  barley  water  for  diluting  the  milk.  This  is  obtained  by  boiling 
the  cereal  ^\ith  water  for  several  hours,  or  by  using  "  prepared  barley," 
a  product  found  in  the  groceries,  which  needs  only  five  minutes' 
boiling. 

If  the  child  has  a  tendency  to  constipation,  I  use  oatmeal  instead 
of  barley  and  molasses  instead  of  sugar,  or  add  a  i^inch  of  bicarbonate 
of  sodium  for  each  bottle.  If,  on  the  other  hand,  there  is  looseness 
of  the  bowels,  rice  may  be  substituted  for  barley. 

Dr.  A.  Seibert  has  given  the  judicious  advice  not  to  determine  the 
composition  and  amount  of  food  by  the  age,  but  by  the  weight  of  the 
child,  and  he  has  devised  the  following  table. 


ARTIFICIAL   IXFAXT  FEEDING. 


Amount  of 

Time  of  Feeding. 

Weight 

of  Child 

in  Pounds. 

Size  of     ,f;,^ 
Bottle.,   ^^"^^• 

Gruel. 

Sugar. 

Interval. 

In  24  Hours. 

6  A.M.  to 
6  P.M. 

6  P.M.  to 
6  A.M. 

6,  7,  or  8 

3  ozs. 

1  oz. 

2  ozs. 

3^  tea- 
spoonful. 

1  bottle 
every  2 
hours. 

8  bottles. 

6  bottles. 

2  bottles. 

9  or  10 

4  ozs. 

13^  ozs. 

23^  ozs. 

1/  t,pa-         1  bottle 

8  bottles. 

6  bottles. 

2  bottles. 

11, 12, 13, 
orll 

5  ozs. 

23^  ozs. 

23^  ozs. 

%  tea- 
spoonful. 

1  bottle 
every  23^ 
hours. 

7  bottles. 

5  bottles. 

2  bottles. 

15  or  16 

6  ozs. 

Z%  ozs. 

23^  ozs. 

%  tea- 
spoonful. 

1  bottle 
every  23^ 
hours. 

7  bottles. 

5  bottles. 

2  bottles. 

17  or  18 

7  ozs. 

5  ozs. 

2  ozs. 

1  tea- 
spoonful. 

1  bottle 
every  3 
hours. 

6  bottles. 

5  bottles 

1  bottle. 

19  or  20 

8  ozs. 

All  milk. 

1  tea- 
spoonful. 

1  bottle 
every  3 
hours. 

6  bottles. 

5  bottles. 

1  bottle. 

Some  recommend  that  salt  be  added  to  the  composition,  and.  since 
cow's  milk  is  deficient  in  this  respect,  the  advice  is  based  on  a  rational 
principle. 

With  such  a  guide  at  hand,  it  would  seem  not  to  be  difficult  to 
bring  up  a  child  artificially,  but  everything  hinges  on  the  quality  of 
the  cow's  milk,  and  that  again  depends  on  the  health  and  food  of  the 


252  NORMAL   PUERPERY. 

COW  and  the  cleanliness  with  which  it  is  kept.  If  the  cow  is  healthy 
and,  especially,  free  from  tuberculosis,  if  it  is  kept  in  a  clean  stable  or 
on  good  pastures,  fed  exclusively  with  grass  or  hay,  its  milk  prepared 
according  to  the  above  rules  will  probably  agree  with  the  infant ;  but 
such  conditions  will  rarely  be  found.  The  vast  majority  are  obliged 
to  buy  their  milk  of  the  milkman,  who  himself  perhaps  does  not 
know  anything  about  the  covv^s  from  which  the  milk  originates.  Cab- 
bages and  beets  are  objectionable  as  food  for  cows  with  whose  milk 
babies  are  nourished,  and  still  more  so  are  swill  and  draff.  There 
is,  therefore,  danger  that  the  milk  is  vitiated  from  the  very  beginning. 
For  mercenary  purposes  the  farmers  or  the  dealers  are  apt  to  dilute 
the  milk  with  water,  and  in  this  way  often  local  epidemics  of  typhoid 
fever  have  been  traced  to  a  pump  or  a  well,  the  water  in  which  was 
contaminated  by  admixture  with  the  drainage  from  privies.  When- 
ever possible  the  milk  from  one  cow  should  be  used,  which  is  easy 
in  the  country.  In  cities  the  milk  should  be  bought  directly  from 
the  milkman  and  not  from  a  grocer,  in  whose  store  it  is  exposed  to 
the  emanations  of  many  substances. 

By  the  addition  of  water  to  the  milk  in  order  to  reduce  the  per- 
centage of  albumin,  that  of  fat  and  sugar  becomes  much  too  low, 
wdiich  may,  however,  be  remedied  by  adding  cream  and  milk  sugar. 
Such  a  mixture  is  the  following : 

R      Cream,  ^iij  (from  milk  that  has  stood  overnight)  ; 

Milk,  |ii  ; 

Water,  ^x  ; 

Milk  sugar,  ^iij. 

Another  difficulty  arises  in  regard  to  bottles  and  nipples.  The 
bottle  should  not  be  larger  than  the  size  indicated  in  the  table,  and 
should  be  kept  scrupulously  clean,  and  so  should  the  nipples.  They 
should  be  of  plain  black  rubber,  and  they  must  neither  let  pass  too 
much  nor  too  little  milk.  In  the  first  case  the  child  is  choked,  in 
the  second  it  gets  tired  of  sucking.  As  a  rule,  three  holes  burnt  with 
a  red-hot  needle  will  give  the  proper  amount  of  milk.  When  not  in 
use  they  should  be  washed  and  kept  in  plain  water.  No  bottles  with 
glass  tubes  should  be  used,  as  they  cannot  be  kept  clean. 

While  being  fed,  the  infant  should  lie  on  its  back  with  the  head  a 
little  raised.  The  bottle  should  be  held  or  placed  so  that  the  bottom 
points  upward  and  the  nipple  against  the  tongue.  In  this  way  the 
child  sucks  with  ease  and  does  not  fill  its  stomach  with  air. 

Condensed  milk,  as  a  rule,  contains  so  much  sugar  that  it  is  unfit 
for  feeding  infants. 

Finally,  we  have  artificial  foods.  They  are  usually  condemned,  but 
I  must  say  that  in  my  own  experience  I  have  often  obtained  success 


CONGENITAL    WEAKNESS.  253 

by  substituting  one  of  them  wlien  milk  caused  diarrhoea.  One  decided 
advantage  they  have  over  most  milk  is  that  the  manufacturer  can 
himself  survey  the  cattle  which  he  uses  and  regulate  their  food.  I  do 
not  see  any  advantage  in  such  preparations  as  are  only  meant  to  be 
added  to  milk,  the  great  difficulty  being  to  get  good  milk,  but  there  are 
several  of  these  foods  which  only  need  to  be  mixed  with  warm  water. 
A  good  preparation  of  this  kind  is  Nestle's  Food,  which  is  prepared 
in  Switzerland  from  the  best  of  cow's  milk  and  wheat  in  which  the 
starch  by  heat  is  changed  into  dextrin.  It  forms  a  chamois-colored 
powder,  one  part  of  which  is  boiled  with  ten  parts  of  water  until  in 
about  ten  minutes  the  mixture  makes  an  even  fluid,  which  is  left  to 
cool  off.  Mothers  must,  however,  be  warned  that  when  the  meal  has 
an  odor  like  old  cheese  it  is  decomposed  and  unfit  for  food.  When 
in  good  condition  it  has  a  pleasant  sweetish  odor,  like  the  cake  called 
"ladies'  fingers," 

This  decomposition  is  not  so  likely  to  take  place  in  products  made 
in  this  country,  and  which,  therefore,  may  reach  the  consumer  in  a 
fresher  condition.  I  have  been  well  satisfied  with  HorlicTcs  Malted 
Milk  and  Reed  and  Carnriclc's  Lacto-preparata  and  Soluble  Food,  which 
only  need  stirring  with  hot  water.  When  the  child  does  not  thrive 
and  gets  intestinal  disturbances,  it  is  necessary  to  change  its  food. 
This  applies  even  to  mother's  milk  and  wet-nurse  milk,  and  so  much 
the  more  to  artificial  food. 

In  general  the  mother  should  nurse  her  child  for  nine  months. 
If  she  is  strong  and  her  milk  good,  the  period  of  lactation  may  even 
be  protracted  to  the  end  of  the  first  year  of  the  child's  life.  But 
then  the  child  should  under  all  circumstances  be  iveaned  and  have 
more  substantial  food,  and  often,  as  we  shall  see  later,  her  milk- 
supply  gives  out  or  becomes  insufficient  long  before  the  end  of  this 
time. 


CHAPTER   VI. 

CONGENITAL   WEAKNESS. 

Premature  or  particularly  weak  children  require  special  care.  It 
has  been  cfuestioned  whether  it  be  wise  to  take  so  much  trouble  in 
rearing  a  puny  being  that  perhaps  may  remain  weak  all  its  life,  a 
burden  to  itself  and  others ;  or  if  it  would  not  be  better,  without 
going  so  far  as  the  Spartans,  who  killed  the  weak  new-born  children, 
at  least  to  refrain  from  taking  special  measures  to  keep  them  alive. 
In  the  author's  opinion,  here  as  always  our  rule  should  be  to  save 
and  prolong  life,  and  therefore  every  effort  should  be  made  to  rescue 
these  poor  little  beings.     Victor  Hugo,  the  greatest  French  author  of 


254 


NORMAL   PUERPERY. 


the  nineteenth  century,  tells  us  that  he  weighed  two  pounds  Avhen  he 
was  born,  and  only  survived  thanks  to  the  utmost  maternal  care. 

Such  weak  children  are  not  only  deficient  in  weight  and  size,  but 
they  move  their  limbs  with  slowness,  the  respiration  is  shallow,  and 
their  cry  feeble.  Sometimes  they  have  not  strength  enough  for  suck- 
ing or  cannot  even  swallow.  The  mortality  among  them  is  enor- 
mous. To  combat  it  we  must  keep  them  warm,  feed  them,  and  try  to 
strengthen  them.  It  is  well  to  rub  them  all  over  with  lukewarm  cod- 
liver  oil,  cover  them,  body  and  head,  except  the  face,  with  a  thick 
layer  of  cotton  batting  held  in  place  with  a  roller  bandage,  and  place 
them  in  a  basket  between  three  hot- water  jugs,  one  on  each  side  and 
one  at  the  feet,  resting  on  a  feather  bed  and  covered  with  a  warm 
but  light  blanket  or  quilt.  Several  times  a  day  they  are  rubbed  all 
over  with  warm  alcohol  and  Avater  or  bathed  in  the  same. 

The  late  Dr.  Tarnier,  of  Paris,  introduced  in  1880  a  great  improve- 
ment in  the  treatment  of  premature  and  weak  children  by  the  inven- 
tion of  the  incubator  (Figs.  242-244). 

FiCr.  242. 


Tarnier's  incubator,  extenor.  (Tarnier  and  Budin,  1.  c.)  O,  opening  full  length  of  box  closed 
with  a  board  that  can  be  pushed  to  either  side ;  M,  so-called  monk,  a  bottle  of  "earthenware  ;  T, 
cover  over  opening  at  end  of  box,  shorter  than  aperture  which  admits  air ;  V,  glass  cover ;  h  b,  but- 
tons by  which  cover  is  easily  lifted ;  H,  wheel  revolved  by  escaping  air. 


This  apparatus  consists  of  a  wooden  box  divided  into  an  upper 
and  a  lower  compartment  communicating  with  each  other  (Fig.  243). 

In  the  lower  are  hot- water  bottles.  In  the  upper  lies  the  child, 
and  in  the  space  uniting  both  hangs  a  wet  sponge.  The  air  enters 
through  the  door  T,  is  heated  by  passing  over  the  hot- water  bottles, 
rises  into  the  upper  compartment,  absorbs  humidity  from  the  sponge, 
and  escapes  through  the  tube  A,  in  which  is  suspended  a  fine  metal 
wheel,  with  wings,  the  movement  of  which  is  proof  of  the  air  circu- 


CONGENITAL   WEAKNESS. 


255 


lating  freely.  The  apparatus  contains  also  a  thermometer,  by  which 
the  temperature  is  measured.  When  the  incubator  is  to  be  used, 
three  earthenware  bottles  (Fig.  244)  full  of  boiling  water  are  placed 
in  the  lower  compartment  and  the  door  is  closed.    In  half  an  hour  the 


Fig.  243. 


Tarnier's  incubator,  interior.    E,  wet  sponge ;  P,  partition  between  lower  and  upper  compartments ; 
A,  tube  for  escape  of  air  ;  T,  M,  V,  66,  as  in  Fig.  242. 

air  rises  to  the  temperature  of  88-90°  F.,  and  the  child  may  be  put 
in  place.  If  the  temperature  in  the  box  rises  higher,  the  glass  cover 
should  be  opened  a  little  for  a  few  minutes.  Two  hours  later  a  fourth 
bottle  with  hot  water  is  introduced,  and  thereafter  one  bottle  at  a  time 
is  emptied  and  filled  again  with  hot  water  every  one  and  a  half  or 
two  hours.  The  child  should  be  dressed  as  we  have  described  above. 
Every  hour  or  two,  according 

to  the  degree  of  weakness  of  ^^"  " 

the    child,    it    is    taken    out, 
cleaned,  and  fed. 

For  these  weak  little  chil- 
dren the  milk  of  the  mother 
or  a  wet-nurse  is  by  far  the 
best  food.  If  the  child  is  too 
weak  to  suckle,  the  milk 
should  be  pressed  or  pumped 
out  and  given  to  it  with  a  teaspoon.  If  the  child  nurses,  it  must  be 
weighed  before  and  after,  in  order  to  ascertain  that  it  gets  enough, 
for  which  purpose  very  delicate  decimal  scales  are  needed.  The 
amount  should,  however,  be  very  small,  only  between  two  and  four 
fluidrachms  at  a  time,  the  weaker  it  is  the  less,  as  too  much  food 
causes  intestinal  disturbances,  which  may  become  fatal  to  the  weak 


Hot-water  jug. 


256  NORMAL    PUERPERY. 

creature.  If  human  milk  camiot  be  secured,  cow's  milk  must  be 
used,  still  more  diluted  than  prescribed  for  a  healthy  baby  and  in  the 
same  small  quantity  as  human  milk.  The  smaller  the  quantity  given 
each  time  the  oftener  it  should  be  repeated,  and  not  less  than  twelve 
times  in  twenty-four  hours. 

If  the  child  is  so  weak  that  it  cannot  suckle,  or  the  food  regurgi- 
tates, it  should  be  fed  by  the  method  called  gavage,  which  likewise 
was  introduced  by  Tarnier.  It  consists  in  laying  the  child  on  its  back 
and  introducing  a  soft-rubber  catheter  (No.  14  or  16,  French)  to  the 
root  of  the  tongue,  when  the  child  itself  instinctively  draws  it  to  the 
upper  end  of  the  oesophagus.  From  here  it  is  easily  pushed  into  the 
stomach.  The  catheter  enters  about  six  inches.  Some  prefer  to  lead 
the  catheter  through  the  nose.  To  the  other  end  of  the  catheter  is 
fastened  a  little  glass  cup,  which  holds  two  fluidrachms.  The  milk 
is  poured  into  this  bulb,  and  sinks  by  gravity  down  into  the  stomach 
of  the  infant.  When  the  proper  quantity  has  been  introduced,  the 
catheter  should  be  withdrawn  rapidly,  as  otherwise  the  milk  is  apt  to 
follow  it. 

When  the  child  improves  it  is  alternately  nourished  by  gavage  and 
put  to  the  breast,  until  finally  it  is  strong  enough  to  suckle  well. 

By  means  of  the  combined  use  of  the  incubator  and  the  gavage  it 
has  been  possible  to  raise  children  after  a  uterogestation  of  only  six 
months. 

If  the  circulation  is  defective,  a  very  cautious  massage  may  be  of 
advantage.  The  skin  is  rubbed  and  the  muscles  are  kneaded  a  little 
two  or  three  times  a  day. 


ABNORMAL    DIVISION 


PART  I.— ABNORMAL  PREGNANCY. 

CHAPTER    I. 
MULTIPLE    FETATION. 

§  1.  Superfecundation. — If  a  mare  is  covered  within  a  short 
interval  by  a  stallion  and  a  jackass,  she  may  give  birth  to  two  colts, 
one  of  which  is  a  horse  and  the  other  a  mule.  This  is  due  to  super- 
fecundation, — that  is  to  say,  after  a  fruitful  connection  with  one 
animal  the  mare  was  again  impregnated  by  the  second.  It  is  not 
unlikely  that  a  similar  event  may  happen  to  a  woman,  but  it  is  hard 
to  prove.  The  fact  that  a  negress  gives  birth  to  two  children,  one  of 
which  is  a  negro  and  the  other  a  mulatto,  proves  only  that  she  has 
had  intercourse  with  a  white  man,  but  it  does  not  prove  that  she  also 
has  had  intercourse  with  a  negro,  because  children  sometimes  take 
almost  exclusively  after  one  of  the  parents.  It  is,  therefore,  possible 
that  both  children  may  have  been  engendered  by  the  same  white  man, 
one  getting  all  the  racial  traits  of  the  mother  and  the  other  being  a 
mixture  of  the  two  races.  It  would,  therefore,  not  be  sure  that  a 
superfecundation  had  taken  place.  Likewise,  if  a  white  woman  gives 
birth  to  a  white  child  and  a  mulatto,  it  is  certain  that  she  has  had 
intercourse  with  a  black  man,  but  it  is  not  proved  that  she  also  has 
had  intercourse  with  a  white  man,  since  the  two  children  might  be 
engendered  by  the  black  father,  one  following  exclusively  the  mother's 
type  and  the  other  showing  the  blending  of  races.  But  since  two  ova 
may  be  loosened  simultaneously  or  within  a  short  interval,  it  is  not 
at  all  unlikely  that  they  might  be  fertilized  by  contact  with  sperma- 
tozoids  derived  from  two  different  fathers. 

§  2.  Superfetation. — If  ovulation  stands  in  causal  connection 
with  menstruation,  and  if  ova  continue  to  be  loosened  after  pregnancy 
has  begun,  which,  as  we  have  seen  above,  is  unlikely,  the  question 
arises  if  such  an  ovum  due  to  a  following  menstruation  can  be  fecun- 
dated, a  condition  which  in  contradistinction  from  superfecundation  is 
called  superfetation.  What  has  led  to  the  supposition  of  such  a  pos- 
sibility is  the  fact  that  in  twin  pregnancies  one  foetus  may  be  much 
less  developed  than  the  other,  and  that  one  twin  may  be  born  con- 
siderably later  than  the  other,  but  this  may  be,  and  probably  is,  due 
to  an  arrest  of  development  of  one  of  the  twins.     After  the  coales- 

17  -  257 


258  ABNORMAL    PREGNANCY. 

cence  of  the  decidua  vera  and  reflexa,  which  takes  place  from  the 
end  of  the  third  month,  it  is  evident  that  a  meeting  between  a  sper- 
matozoid  and  an  ovum  becomes  an  impossibihty ;  but  even  long 
before  that  time  it  is  likely  that  the  swelling  of  the  decidua  around 
the  apertures  of  the  tubes  becomes  so  great  as  to  oppose  an  msur- 
mountable  barrier,  and  at  the  other  end  of  the  uterus  there  is  another 
barrier  formed  by  a  large  plug  of  thick  mucus  filling  the  cervical  canal. 

§  3.  Common  Multiple  Fetation. — Apart  from  the  question  of 
superfecundation  and  superfetation  resulting  from  repeated  intercourse 
with  the  same  or  different  individuals,  a  single  coition  may  result  in 
the  development  of  two  or  more  foetuses.  One  Graafian  follicle  has 
been  seen  to  contain  two  ova,  and  two  or  more  Graafian  follicles  may- 
rupture  at  the  same  time.  Finally,  a  single  ovum  may  contam  two 
or  more  germinative  vesicles,  which  become  fertilized  and  develop 
separate  foetuses ;  or  a  single  germ  may  by  scission  be  the  origin  of 
multiple  fetation.  Heredity  and  racial  differences  have  some  influence 
in  this  respect.  In  some  families  the  recurrence  of  twin  pregnancies 
is  a  frequent  event,  and  the  woman  who  once  gives  birth  to  twins  is 
more  apt  to  do  so  again  than  another  woman.  Fruitful  races,  like 
Hebrews,  Russians,  and  Italians,  seem  to  possess  a  predisposition  to 
multiple  fetation.  But  upon  the  whole  this  occurrence  is  so  rare  and 
so  often  gives  rise  to  disturbances  during  pregnancy  or  complications 
during  labor  that  it  must  be  looked  upon  as  an  abnormal  event. 
Only  one  birth  in  eighty-nine  is  a  twin  birth.  Triplets  are  found 
only  once  in  about  eight  thousand  confinements,  and  quadruplets 
once  in  about  four  hundred  thousand.  Five  children  at  once  are  still 
rarer,  and  the  largest  number  ever  recorded  by  medical  men  is  six. 

If  a  woman  has  a  double  uterus,  she  is  more  apt  to  get  twins,  and 
superfecundation  or  superfetation  could  more  easily  occur  than  m  a 
single  uterus.  In  such  a  case  there  would  also  be  two  deciduae  verge, 
while  under  all  other  circumstances  there  is  only  one.  In  a  single 
uterus  the  multiple  foetuses  may  be  found  in  one  or  more  ova.  If 
there  is  only  one  ovum,  there  is  also  only  one  reflexa ;  and  even  if 
there  are  more  ova,  if  they  are  engrafted  near  one  another,  they  may 
all  be  covered  by  the  same  reflexa;  but  if  the  implantation  takes 
place  with  a  greater  interval,  each  ovum  has  its  own  reflexa. 

As  to  the  chorion,  it  is  single  if  there  is  only  one  ovum,  but  if 
there  are  several  each  has  its  own  chorion.  Each  fretus  has  also  its 
own  amnion,  but  in  course  of  time  the  partition  between  the  two  may 
become  absorbed,  so  as  to  form  one  cavity,  or,  if  the  twms  are  devel- 
oped through  scission  of  one  germ,  the  formation  of  the  amnia  may 
be  defective,  just  as  the  foetuses  themselves  may  be  imperfectly  sepa- 
rated. Whether  a  twin  pregnancy  is  developed  in  one  or  two  ova 
can,  therefore,  be  decided  by  examining  the  partition  between  the  two 


MULTIPLE    FETATION. 


259 


Fig.  245. 


foetuses.  If  there  is  none  or  only  a  double  layer  of  amnion,  the  twin 
pregnancy  has  developed  in  a  single  ovum  ;  but  if  the  partition  besides 
contains  two  layers  of  chorion,  and  perhaps  two  layers  of  decidua, 
the  two  foetuses  have  developed  in  two  separate  ova. 

If  there  are  two  ova,  there  may  also  be  two  separate  placentae,  but 
they  may  be  more  or  less  grown  together.  If  the  ovum  is  single,  there 
is  only  one  common  placenta  for  both  twins. 

Twins  developed  in  one  ovum  are  often  remarkably  alike  in  size, 
features,  and  mental  faculties. 

As  a  rule,  each  foetus  in  multiple  fetation  weighs  less  and  is  smaller 
than  an  average  single  child,  but  taken  altogether  they  weigh  more 
than  when  there  is  only  one. 

In  a  common  ovum  the  navel-cords  may  become  so  entangled 
that  both  foetuses  die.  One  twin 
may  be  developed  at  the  cost  of  the 
other,  so  as  to  be  larger.  One  may 
be  so  compressed  by  the  other  that 
it  dies  and  becomes  mummified, 
thin,  and  flat, — a  so-called  foetus 
papyraceus.  Beside  a  normally  de- 
veloped twin,  there  may  be  another 
who  has  no  heart  and  is  nourished 
through  the  other  twin.  This  anom- 
aly, called  acardiacus  (Fig.  245),  is 
found  only  where  the  ovum  is  sin- 
gle. It  is  due  to  the  allantois  of  one 
of  the  foetuses  covering  all  or  nearly 
all  of  the  decidua  serotina.  Tlie 
blood-pressure  in  this  one  becomes 
so  much  greater  than  in  the  other 
that  the  circulation  in  the  latter  be- 
comes reversed.  Heart  and  lungs 
and  more  or  less  of  the  body  atro- 
phy, and  the  pressure  in  the  umbilical  vein  often  gives  rise  to  consid- 
erable oedema  of  the  subcutaneous  connective  tissue. 

Sometimes  one  ovum  contains  an  abnormal  amount  of  liquor 
amnii  (hydrcmmion),  while  the  other  is  normal. 

The  sex  in  twins  varies.  In  more  than  one-third  of  all  cases  the 
two  are  of  opposite  sex.  Next  in  frequency  come  two  males,  and  the 
rarest  combination  is  that  of  two  females. 

Diagnosis. — In  most  cases  the  diagnosis  is  not  made  before  the 
birth  of  the  first  child,  when  it  becomes  an  easy  matter  to  feel  through 
the  abdominal  wall  that  the  uterus  contains  another  cliild,  and  vaginal 
examination  reveals  the  formation  of  a  second  bag  of  waters.     Before 


Acardiacus.     (Voii  Franque,  Sr. 


260  ABNORMAL    PREGNANCY. 

delivery  it  is  by  no  means  an  easy  matter  to  diagnosticate  the  presence 
of  two  foetuses  in  the  uterus.  Unusual  discomfort,  dyspnoea,  oedema, 
a  size  of  the  abdomen  which  is  larger  than  that  corresponding  to  the 
period  of  gestation,  and  wide-spread  fetal  movements  may,  in  a  general 
way,  lead  us  to  suspect  the  presence  of  a  multiple  fetation.  Sometimes 
a  distinct  furrow  may  be  seen  running  between  the  two  foetuses.  It 
may  be  possible  to  feel  distinctly  the  two  heads  or  more  limbs  than 
correspond  to  one  child.  Auscultation  may  perhaps  solve  the  doubt. 
It  is,  however,  not  enough  for  a  diagnosis  that  the  accoucheur  hears 
the  fetal  heart  pulsate  with  different  frequency  on  different  points  of 
the  abdomen,  because  the  pulsation  of  the  same  heart  may  vary  con- 
siderably from  one  moment  to  the  other.  In  order  to  be  conclu- 
sive, the  auscultation  must  be  performed  simultaneously  by  two  per- 
sons with  practised  ears,  and  even  then  the  experiment  ought  to  be 
repeated.  If  the  two  at  the  same  time  get  a  different  number  of 
pulsations,  there  must  be  two  hearts.  The  writer  has  been  deceived 
by  palpation  in  a  case  of  foothng  presentation,  feeling  both  legs  and 
what  he  took  to  be  the  skull  through  the  vagina  and  another  head 
under  the  liver.  As  a  curiosity  I  may  mention  that  the  mother  all 
her  life  had  the  habit  of  drawing  up  her  legs  and  crossing  them  hke  a 
Turk,  and  her  child  occupied  exactly  the  same  position  in  her  uterus, 
the  breech  resting  in  the  left  iliac  fossa  and  the  legs  being  crossed 
over  the  cervix.  If  heart-sounds  are  audible,  and  vaginal  examina- 
tion proves  that  the  head  is  easily  compressible  and  its  bones  freely 
movable,  or  a  prolapsed  pulseless  cord  is  felt,  it  is  evident  that  there 
is  one  living  and  one  dead  child.  Very  rarely  two  bags  may  be  felt 
simultaneously,  which  also  is  certain  proof  of  multiple  pregnancy. 
Triplets  can  hardly  be  diagnosticated  before  delivery. 

Prognosis. — The  prognosis  is  less  good  in  multiple  fetation  than  in 
single  pregnancy.  The  woman  is  more  apt  to  suffer  during  pregnancy. 
Labor,  as  a  rule,  comes  on  before  the  time.  The  uterine  contractions 
are  often  weak.  Frequently  operative  interference  becomes  necessary. 
There  is  danger  of  post-partum  hemorrhage,  renal  disease,  eclampsia, 
or  puerperal  infection.  The  children  are  smaller  and  weaker,  usually 
the  mother  has  not  milk  enough  to  nurse  them,  and,  as  a  result,  we 
find  an  enormous  mortality  among  them  during  the  first  year,  which 
is  still  more  applicable  when  the  number  exceeds  two. 


THE    DEATH    OF    THE    F(ETUS.  261 

CHAPTER    11. 

THE   DEATH    OF   THE    F(ETUS. 

Symptoms. — It  happens  not  infrequently  that  the  foetus  dies  in  the 
mother's  womb.  The  first  sign  that  calls  attention  to  such  a  con- 
dition is  the  cessation  of  fetal  movements,  especially  if  it  follows 
unusual  strength  and  frequency  of  motion,  but  sometimes  the  foetus 
keeps  so  quiet  that  for  a  day  no  movements  are  felt  by  the  mother, 
although  it  is  alive.  After  the  beginning  of  labor  the  movements 
are  rarely  felt.  The  same  incertitude  may  obtain  in  regard  to  the 
heart  sounds.  When  the  foetus  dies  the  heart  ceases  pulsating,  but 
the  foetus  may  change  its  position  m  such  a  way  that  the  sounds 
which  have  been  heard  before  are  no  longer  audible,  and  still  the 
child  may  be  alive. 

When  the  foetus  dies,  certain  changes  take  place  in  the  mother 
which  have  more  or  less  diagnostic  value.  Her  breath  may  become 
offensive.  She  may  have  dark  rings  under  the  eyes.  Her  face  may 
become  pale.  The  breasts  may  shrink.  She  may  have  fever,  and 
even  shiver.  She  maybe  mentally  depressed.  She  does  not  increase 
in  size,  and  it  is  even  asserted  that  she  loses  from  four  to  six  pounds 
in  weight.  Often  she  has  a  sensation  of  a  heavy  body  rolling  in  her 
abdomen  when  she  moves.  It  has  also  been  contended  that  the 
presence  of  acetonuria  is  a  sure  sign  of  the  death  of  the  foetus,  but  the 
writer  has  found  it  present  with  a  live  foetus  and  absent  when  the 
foetus  was  dead.  During  pregnancy  the  uterus  has  a  higher  tempera- 
ture than  the  vagina,  the  living  foetus  being  a  source  of  heat.  But 
after  the  death  of  the  foetus  the  temperature  in  both  is  the  same.  A 
sure  sign  of  the  death  of  the  foetus  is  found  in  an  abnormal  mobility 
of  the  bones  of  the  cranium. 

After  its  death  the  foetus  is  sooner  or  later  expelled  from  the  body 
of  its  mother  by  abortion  or  premature  labor,  which,  as  a  rule,  takes 
place  within  two  weeks  after  the  death  of  the  foetus.  During  this 
time  the  foetus  undergoes  certain  changes.  The  red  blood-corpuscles 
are  dissolved,  forming  a  red  serum,  which  pervades  its  whole  body 
and  also  imparts  a  dark  bloody  color  to  the  liquor  amnii. 

Etiology. — The  death  of  the  foetus  may  be  due  to  injury.  When 
during  pregnancy  the  uterus  rises  into  the  abdominal  cavity,  the  foetus 
becomes  exposed  to  injury  through  the  abdominal  wall,  such  as  goring 
with  the  horn  of  an  infuriated  bull,  kicks  with  the  heavy  boot  of  a 
no  less  brutal  man,  stab-wounds,  or  shot-wounds.  I  have  seen  the 
gravid  uterus  taken  for  a  fibrocyst  of  the  uterus,  or  even  an  ovarian 
cyst,  and  punctured  by  the  surgeon  in  performing  laparotomy,  Avhich 
may  necessitate  the  removal  of  the  foetus ;  or,  even  if  the  ovum  is 


262  ABNORMAL    PREGXAXCY. 

intact  and  the  wound  properly  stitched,  in  most  cases  ends  in 
abortion. 

Another  class  of  injuries  is  inflicted  through  the  vagina  and  the 
cer'VTx,  in  order  to  bring  on  abortion,  either  legitimately  by  the 
accoucheur  in  the  interest  of  the  mother  or  criminally  by  abortionists. 

In  most  instances  the  death  of  the  foetus  is  due  to  some  disease  of 
the  mother,  especially  acute  diseases  accompanied  by  high  tempera- 
ture, such  as  pneumonia,  typhoid  fever,  small-pox,  or  Asiatic  cholera ; 
poisoning  with  lead,  phosphorus,  or  bisulphide  of  carbon,  a  substance 
used  much  m  industry  as  a  solvent  for  vegetable  oil  and  rubber ;  per- 
nicious anaemia ;  inflamed  kidneys  "with  eclampsia ;  and,  most  of  all, 
syphilis  in  the  mother,  the  father,  or  both. 

Certain  drugs,  such  as  ergot,  gossypii  radicis  cortex,  oleum  hedeomae, 
oleum  sabinae,  permanganate  of  potassium,  or  the  binoxide  of  man- 
ganese, oleum  rutsQ,  oleum  tanaceti,  tinctura  cantharidis,  tinctura  hel- 
lebori  nigri,  strychnine,  etc.,  are  apt  to  produce  abortion,  and  are  often 
taken  by  women  for  this  puri3ose. 

Treatment. — If  the  death  of  the  foetus  is  brought  about  by  internal 
causes,  a  purely  expectant  treatment  is  inchcated  until  the  foetus  is 
expelled.  What  is  called  for  thereafter  will  be  discussed  in  the  next 
chapter,  m  treating  of  abortion. 

If  the  death  of  the  foetus  is  due  to  a  wound,  such  as  goring  with 
the  horn  of  an  animal,  the  case  must  be  treated  according  to  the  gen- 
eral rules  of  surgery.  The  prognosis  in  such  cases  is  better  than  one 
would  expect.  The  late  Robert  P.  Harris  collected  fourteen  cases 
with  nine  recoveries. 


CHAPTER    III. 

INTERRUPTIOX    OF    PREGXAXCY. 

§  1.  Abortion. — Abortion,  or  miscarriage,  is  the  interruption  of 
pregnancy  before  the  child  is  viable.  As  we  have  seen  alDove,  this  is 
at  the  end  of  six  months  of  uterogestation,  which  thus  forms  a  natural 
Imiit  between  abortion  and  premature  labor. 

Frequency. — There  is  no  means  of  ascertaining  how  frequently 
abortion  occurs,  but  it  is  doulDtless  quite  a  common  event.  Some 
estimate  that  one  abortion  corresponds  to  every  eight  or  ten  confine- 
ments, while  others  think  it  happens  twice  as  often.  Many  abortions, 
doubtless,  pass  without  anybody,  not  even  the  woman  concerned, 
knowing  that  she  was  pregnant.  Menstrual  irregularities,  which  are 
so  common  in  recently-married  women,  are  probably  often  due  to 
incipient  pregnancy  and  its  untmiely  interruption.     The  writer  has 


INTERRUPTION    OF    PREGNANCY.  263 

while  treating  a  gynaecological  patient  accidentally  seen  an  ovum 
thrown  off  at  the  end  of  the  second  week  after  coition  without  the 
patient  knowing  that  she  was  pregnant  or  had  aborted,  there  being 
no  symptoms  whatsoever  to  call  her  attention  to  it. 

Abortion  is  most  common  in  the  third  month  of  pregnancy,  and  is 
observed  with  diminishing  frec|uency  m  the  second,  fourth,  fifth,  and 
sixth  months.  Perhaps  it  is  more  frec|uent  during  the  first  and  second 
months,  but  passes  unnoticed  ;  when  the  foetus  is  larger,  this,  of  course, 
cannot  happen. 

The  chief  symptom  of  aljortion  is  hemorrhage  from  the  uterus, 
which  precedes,  accompanies,  and  follows  the  miscarriage.  When 
abortion  actually  occurs,  clots  are  discharged,  but  in  some  cases 
nothing  is  observed,  so  that  the  patient  is  in  doubt  whether  she 
has  aborted  or  not.  When  a  woman  who  usually  menstruates  with 
regularity  has  skipped  a  period  and  then  is  seized  with  cramps  and 
passes  clots,  the  probability  is  great  that  she  has  aborted.  If  the 
entire  ovum  or  part  of  it  or  the  foetus  itself  is  expelled  and  seen, 
there  is  no  longer  any  doubt ;  and  in  cases  of  expected  abortion  the 
physician  should,  therefore,  give  strict  orders  that  all  clots  or  shreds 
or  anything  that  resembles  part  of  a  body  shall  be  kept  for  his  exami- 
nation. The  smallest  twig  of  a  villus  of  the  chorion  examined  under 
the  microscope  is  sufficient  to  make  the  diagnosis  that  it  comes  from 
an  ovum,  while  a  tissue  composed  of  the  large  decidual  cells  only 
proves  that  the  patient  is  pregnant,  but  not  that  the  uterus  contains 
an  ovum,  which  may  have  developed  in  an  abnormal  place. 

The  loss  of  blood  may  be  so  great  that  the  patient  becomes  faint, 
loses  consciousness,  or  even  dies.  The  hemorrhage  may  last  for 
days,  weeks,  or  months,  and  in  these  protracted  cases,  even  if  it  is 
moderate,  it  weakens  the  woman  considerably. 

In  most  cases  there  is  some  pain,  which  is  described  as  being 
cramp-like,  and  is  due  to  painful  contractions  of  the  uterus.  Back- 
ache is  also  a  common  symptom.  Often  the  patient  complains  of 
nausea,  or  vomits  and  yawns. 

On  vaginal  examination  the  uterus  is  found  enlarged,  soft,  and,  as 
a  rule,  either  retroflexed  or  anteflexed.  The  os  is  more  or  less  patu- 
lous, sometimes  sufficiently  so  to  admit  the  fmger.  Often  the  ovum 
may  be  felt  projecting  from  the  os,  or,  if  the  foetus  has  been  expelled, 
the  umbilical  cord  may  hang  out  from  the  os.  In  other  cases  the  os 
is  closed.  Nearly  always  there  is  a  more  or  less  profuse  bloody  dis- 
charge from  the  uterus.  If  the  foetus  is  macerated,  there  may  be  an 
offensive  purulent  discharge.  If  general  septicaemia  has  developed, 
the  pulse  is  small  and  rapid,  and  sometimes  the  temperature  is  ele- 
vated. Under  such  circumstances  there  may  also  be  weakness,  nausea, 
vomiting,  and  a  yellowish  color  of  the  face.     In  a  case  of  this  kind 


264 


ABNORMAL    PREGNANCY. 


the  writer  saw  repeated  epistaxis  and  the  formation  of  a  large  retro- 
uterine haematocele,  which  led  to  a  fatal  termination. 

In  very  early  pregnancy  the  entire  ovum  may  be  expelled  at  once, 
and  the  remaining  decidua  be  so  insignificant  that  it  will  take  care  of 
itself  and  cause  as  little  trouble  as  at  the  end  of  pregnancy — complete 
abortion  (Fig.  246).  In  other  cases  the  reflexa  is  expelled  with  the 
ovum,  and  torn  off  from  the  vera,  which  remains.  In  others,  again, 
blood  accumulates  between  the  chorion  and  the  reflexa,  and  sepa- 
rates the  ovum  from  the  reflexa,  which  may  rupture,  permitting  the 
ovum  to  escape,  while  the  whole  decidua  remains  in  the  uterus.  In 
other  instances,  again,  the  foetus  alone  escapes,  and  the  whole  ovum 


Fig.  246. 


t^.w€:A 


Abortive  ovum  expelled  together  with  the  whole  decidua.    (Olshausen-Veit.)    o.t.  corresponds  to 
the  internal  os  ;  t  and  t',  to  the  uterine  orifices  of  the  tubes. 

is  retained — incomplete  abortion.  Sometimes  a  well-formed  foetus  is 
found  among  the  expelled  masses,  but  in  others  it  is  only  represented 
by  a  formless  mass,  even  when  the  ovum  is  thrown  off  intact. 

Etiology. — Numerous  are  the  agencies  that  may  lead  to  abortion. 
In  most  cases  the  cause  is  to  be  found  in  the  mother,  but  it  may  also 
exceptionally  be  of  fetal  origin.  We  distinguish  between  predisposing 
and  exciting  causes.  Among  the  former  endometritis  often  produces 
abortion.  The  inflamed  endometrium  does  not  form  a  favorable  soil 
for  the  implantation  of  the  ovum,  which,  instead  of  developing  in  the 
upper  part  of  the  uterus,  either  slides  down  and  is  grafted  on  the 
lower  uterine  segment  or  is  washed  out  altogether.  Or  the  hyper- 
trophy of  the  connective  tissue  compresses  the  blood-vessels  through 
which  nourishment  and  oxygen  are  carried  to  the  foetus.    Deep  lacer- 


INTERRUPTION   OF   PREGNANCY.  265 

ations  of  the  cervix  deprive  the  ovum  of  some  of  the  support  it  nor- 
mally should  find  in  that  organ.  Retroflexion  of  the  uterus  destroys 
the  normal  relations  between  the  axis  of  the  uterus  and  that  of  the 
vagina,  and  leaves  the  parturient  canal  in  a  direction  much  more  favor- 
able to  the  expulsion  of  the  contents  of  the  uterus  than  when  it  has 
its  normal,  somewhat  anteflexed  shape,  forming  an  acute  angle  with 
the  vagina.  As  a  rule,  the  retroflexed  uterus,  increasing  in  size,  rises 
out  of  the  pelvis  and  becomes  anteflexed.  But  sometimes  it  becomes 
impacted,  and  the  condition  ends  in  abortion.  Anteflexion,  although 
nearer  to  the  normal  relation  between  cervix  and  body,  interferes 
with  the  normal  development  of  the  uterus  during  pregnancy,  and 
may  lead  to  early  abortion.  Myomas  are  accompanied  by  endometri- 
tis, and  may,  by  their  bulk,  interfere  with  the  free  development  of  the 
ovum. 

Among  fetal  conditions  the  vesicular  mole  ends  frequently  in 
abortion,  and  hypertrophy  of  the  villi  may  press  on  the  blood- 
vessels upon  which  the  foetus  depends  for  its  nourishment.  That 
disease  of  the  ovum  entirely  independent  of  the  maternal  organism 
may  lead  to  abortion  is  seen  in  the  cases  of  congenital  syphilis  in 
which  the  taint  is  inherited  only  from  the  father,  the  mother  remain- 
ing healthy. 

When  some  predisposing  cause  is  present,  even  slight  concussions, 
such  as  coughing,  sneezing,  vomiting,  may  become  the  exciting  cause 
of  abortion.  That  even  without  particular  predisposition  pregnancy 
may  be  interrupted  by  blows  and  kicks  on  the  abdomen  of  the  preg- 
nant woman,  and  still  more  by  penetrating  wounds  inflicted  with 
sharp  instruments  or  fire-arms,  is  evident.  In  this  category  must  also 
be  counted  violent  coition.  Alcoholic  abuse  may  become  the  cause 
of  abortion  by  overexcitation  of  the  circulatory  system.  Acute  dis- 
eases accompanied  by  a  Ijigh  temperature  are  very  apt  to  be  accom- 
panied by  abortion,  and  among  chronic  diseases  syphilis  is  the  most 
common  cause.  Valvular  heart  disease  may  also  become  the  starting- 
point  of  abortion,  a  stasis  of  blood  being  caused  in  the  vessels  con- 
necting with  the  ovum. 

When  the  foetus  dies,  abortion  must  follow.  All  causes  of  fetal 
death  enumerated  in  the  preceding  chapter,  besides  those  which  we 
have  just  spoken  of,  become,  therefore,  also  indirectly  causes  of 
abortion. 

Low  temperature  is  said  to  cause  abortion  as  well  as  overheating. 
Pulling  on  the  nipples  may  cause  uterine  contraction  and  end  in  abor- 
tion. This  manipulation,  recommended  for  elongating  defective  nip- 
ples, must,  therefore,  be  watched  with  care.  Perhaps  the  normal 
congestion  that  takes  place  at  each  menstruation  continues  during 
pregnancy,  although  the  menstrual  flow  is  interrupted.     Particular 


266  ABNORMAL   PREGNANCY. 

care  should,  therefore,  be  taken  at  these  periods  by  women  who  are 
inclined  to  miscarry. 

Prognosis. — The  prognosis  depends  much  on  the  treatment.  In 
a  general  way  it  may  be  stated  that  most  women  are  far  from  paying 
sufficient  attention  to  a  miscarriage,  and  that  they  often  are  severely 
punished  for  their  foolhardiness  and  neglect.  The  two  great  dangers 
are  hemorrhage  and  septicEemia,  either  of  which,  especially  the  latter, 
may  end  in  death. 

Treatment} — Being  called  to  a  case  of  threatening  abortion,  the 
first  question  the  practitioner  should  ask  himself  is,  "  Can  abortion 
still  be  averted  ?"  If  the  hemorrhage  is  considerable  or  has  continued 
for  days  or  weeks,  if  the  cervical  canal  is  open,  and  if  the  ovum  is 
felt  projecting  into  the  vagma,  abortion  is  inevitable,  and  then  no  tmie 
should  be  lost  in  temporizing.  But  if  the  loss  of  blood  is  moderate 
and  the  cervix  closed,  an  attempt  should  be  made  to  avoid  the  inter- 
ruption of  pregnancy.  For  this  purpose  the  patient  should  be  kept 
in  bed.  A  suppository  with  a  grain  of  pulvis  opii  should  be  inserted 
into  the  rectum  every  three  hours,  unless  it  cause  dizziness  or  nausea, 
when  the  interval  is  made  longer — say  from  four  to  six  hours.  If  the 
bowels  do  not  act  freely,  a  saline  aperient,  especially  a  heaping  tea- 
spoonful  of  sodium  sulphate  dissolved  in  a  tumblerful  of  water,"  should 
be  administered  by  the  mouth,  and,  if  necessary,  repeated  every  four 
hours.  Finally,  a  teaspoonful  of  the  fluid  extract  of  viburnum  pruni- 
folium  should  be  given  three  times  a  day,  a  drug  which  has  a  marked 
soothing  influence  on  the  uterus  and  counteracts  contraction.  Dr. 
Stephen  Harrisberger,  of  Catlet,  Virginia,  praises  acetanilid  (gr.  iv — 
25  centigrammes — every  two  hours  while  abortion  threatens). 

The  diet  should  be  cool  and  bland.  Alcoholic  drinks  and  coffee 
should  be  forbidden.  Iced  milk  and  fruit  are  appropriate,  and  should, 
in  connection  with  bread,  butter,  and  cold  meat,  constitute  the  menu. 
I  have  often  combined  the  above  treatment  with  the  application  of  an 
ice-bag  to  the  hypogastric  region,  but  if  the  assertion  that  an  extremely 
low  temperature  is  as  apt  as  a  high  one  to  produce  abortion  is  well 
founded,  it  may  be  safer  to  omit  it. 

If  alDortion  cannot  be  prevented,  the  question  how  to  act  presents 
itself.  The  old  treatment,  consisting  in  vaginal  injections  of  ice-water, 
tamponade,  and  removal  of  the  ovum  when  it  lies  loose  in  the  vagina 
or  is  easily  separated  from  the  uterus  with  the  finger,  exposes  the 
patient  to  great  danger  of  hemorrhage  or  septiccemia.  We  have  seen 
above  that  in  very  early  pregnancy — during  the  first  month  and  part 
of  the  second — the  entire  ovum  may  be  expelled  and  hardly  anything 
be  left  of  the  decidua.     In  such  cases  resort  may  be  had  to  tamponade. 

^  Garrigues,  "The  Treatment  of  Abortion,"  Medical  News,  November  6, 
1897. 


INTERRUPTION    OF   PREGNANCY.  267 

This  is  especially  indicated  if  the  patient  is  in  so  weak  a  condition 
when  seen  that  it  is  deemed  wise  to  let  her  have  time  to  recuperate 
before  recourse  is  had  to  more  active  operative  interference,  or  if  she 
has  to  be  removed  to  a  hospital. 

With  these  exceptions,  the  best  treatment  consists  in  curettage, 
previous  to  which  the  cervix  must  be  dilated  if  it  is  not  open.  (See 
Operations.) 

The  intra- uterine  use  of  steam — atmokausis,  or  vaporization — has 
been  recommended  in  abortion  cases.  Being  perfectly  satisfied  with 
my  results,  I  have  not  felt  like  subjecting  the  patients  to  a  procedure 
which  I  have  tried  for  other  purposes,  especially  hemorrhagic  endo- 
metritis, and  found  to  give  rise  to  a  protracted  purulent  discharge,  and 
which  in  the  hands  of  others  has  led  to  complete  closure  of  the  uter- 
ine canal,  and  even  to  death. ^ 

By  carrying  out  the  treatment  above  described  I  have  never  lost  a 
case,  and  there  has  not  even  been  any  kind  of  untoward  complica- 
tion. On  the  other  hand,  I  have  seen  a  number  of  cases  in  which  I 
was  first  called  when  septicaemia  had  developed  end  in  death.  In 
these  septic  cases  our  resources  are  limited,  and  the  prognosis  should 
be  very  guarded.  There  may  even  be  considerable  doubt  in  regard  to 
the  best  way  of  treating  them.  If  the  fcetus,  ovum,  or  placenta  is 
retained  or  if  there  is  hemorrhage,  the  cervix  must  be  dilated  and  the 
uterus  curetted  and  irrigated.  If,  on  the  other  hand,  it  is  doubtful 
if  anything  remains  in  the  uterus,  it  is  often  better  to  refrain  from 
curetting,  as  by  this  operation  the  protective  wall  of  leucocytes  which 
nature  has  thrown  out  beyond  the  affected  part  may  be  destroyed, 
and  pathogenic  germs  given  a  ready  means  of  penetrating  to  the 
deeper,  hitherto  unaffected  tissues. 

The  writer  has  even  seen  cases  in  which  the  mere  introduction  of 
an  intra-uterine  tube  for  washing  out  the  uterus  regularly  caused  a 
rise  in  temperature,  and  the  patients  recovered  after  all  intra-uterine 
treatment  had  been  discontinued. 

In  these  septic  cases  a  chief  indication  is  to  keep  up  the  flagging 
strength  by  means  of  alcohol  and  strychnine.  The  patient  should  be 
given  twelve  ounces  or  more  of  whiskey  or  brandy  during  the  twenty- 
four  hours.  Among  wealthy  patients  champagne  may  be  substituted. 
She  should  also  have  plenty  of  milk,  eggs  beaten  up  with  milk, 
bouillon  or  chicken  broth,  beef  juice,  and  strong  beef  tea.^ 

Quinine  or  salophen  in  five-grain  doses  every  three  or  four  hours 
seems  sometimes  to  have  a  good  effect. 

Some  have  recommended  the  subcutaneous  injection  of  anti- 
streptococcus  serum,  but  this  substance  seems  to  have  little  effect. 

^  See  Garrigues,  A  Text-book  of  the  Diseases  of  Women,  third  ed.,  p.  187. 
^  See  Garrigues,  ibid.,  p.  iJ40. 


268  ABNORMAL   PREGNANCY. 

At  best  it  does  not  seem  to  have  any  deleterious  effect  upon  the 
patient.^    Other  remedies  will  be  discussed  under  Puerperal  Infection. 

As  a  last  resort  the  cjuestion  of  hysterectomy  presents  itself. 
What  could  be  more  rational  than  to  remove  the  starting-point  of  the 
infection,  even  at  the  cost  of  lifelong  sterility  and  considerable  risk  to 
life  from  the  operation  itself?  But,  unfortunately,  when  the  condition 
is  sufficiently  serious  to  warrant  so  dangerous  an  interference,  during 
which  the  patient  may  die  on  the  table,  the  infection  is  of  so  virulent 
a  nature  and  has  progressed  so  far  that  no  help  is  longer  possible. 
To  have  recourse  to  this  mutilation  in  mild  cases  of  sepsis  must  be 
condemned,  as  the  patients  in  all  likelihood  would  recover  under  a 
more  palliative  treatment. 

§  2.  Habitual  Abortion. — Some  w^omen  have  so  great  a  tendency 
to  abortion  that  the  event  is  repeated  every  time  they  get  pregnant. 
The  writer  has  seen  a  case  in  which  nine  abortions  were  finally  fol- 
lowed by  the  birth  of  a  child  at  term.  The  causes  of  this  tendency 
are  the  same  as  some  of  those  mentioned  in  speaking  of  the  etiology 
of  abortion,  and  these  remaining  unchanged  the  effect  is  also  repeated. 
By  far  the  most  common  is  syphilis ;  but  uncorrected  uterine  dis- 
placements, unrepaired  tears  of  the  cervix,  chronic  infection  with  the 
Plasmodium  of  malaria,  or  exposure  to  the  influence  of  carbon  bisul- 
phide may  bring  about  a  similar  condition.  If  some  such  permanent 
cause  is  found,  the  first  indication  is  to  try  to  remove  it.  By  insti- 
tuting an  antisyphilitic  treatment  of  the  husband,  the  wife,  or  both,  we 
may  sometimes  succeed  in  eliminating  the  materia  peccans,  and  thus 
helping  our  patient  to  get  her  hitherto  frustrated  desire  of  offspring 
fulfilled.  It  may  be  necessary  for  the  patient  to  leave  a  malarious 
district,  to  change  her  occupation,  or  to  undergo  an  operation  for  dis- 
placement of  the  uterus  or  a  torn  cervix. 

Some  have  recommended  absolute  rest  during  pregnancy,  but  this 
is,  in  the  writer's  opinion,  weakening,  and  may  indirectly  contribute 
to  a  miscarriage  or  leave  the  patient  in  a  less  favorable  condition  for 
the  ordeal  of  childbirth.  On  the  other  hand,  the  author  has  repeat- 
edly succeeded  in  preventing  habitual  abortion  by  ordering  the  patient 
to  lie  in  bed  or  on  a  lounge  during  a  week  corresponding  to  the  men- 
strual period.  Rest  should  begin  two  days  before  menstruation  would 
be  due  if  pregnancy  had  not  supervened,  and  be  continued  five  days 
after  that  time.  During  this  week  I  give  a  teaspoonful  of  the  fluid 
extract  of  viburnum  prunifolium,  or,  since  the  taste  of  this  drug  is 
very  disagreeable  to  most  patients,  I  have  it  inspissated  and  adminis- 
tered in  gelatin  capsules.  During  the  remaining  three  weeks  mod- 
erate exercise  in  the  open  air  and  the  use  of  iron,  quinine,  red  bone 

^  Report  of  Committee  appointed  by  the  American  Gynfecological  Society, 
Trans.,  1899,  vol.  xxiv.  p.  105. 


INTERRUPTION    OF    PREGNANCY.  269 

marrow,  and  arsenic  are  beneficial.  Coition,  dancing,  horseback 
riding,  bicycling,  gymnastics,  and  all  kinds  of  sports  or  fatiguing  work 
must  be  absolutely  forbidden.  J.  Y.  Simpson  recommended  chlorate 
of  potassium  (gr.  xv  to  xx — 1  gramme  to  1.30  gramme — t.  i.  d.),  with 
a  view  of  furnishing  oxygen  to  the  foetus,  which  doubtless  might  be 
obtained  in  a  much  more  effective  way  by  inhalation  of  the  gas,  but 
others  have  thought  they  had  good  effects  from  the  use  of  the  drug 
independently  of  the  theory. 

§  3.  Artificial  Abortion.' — Instead  of  trying  to  prevent  or  treat- 
ing abortion  when  it  threatens  or  has  occurred,  it  sometimes  becomes 
the  duty  of  the  conscientious  physician  to  bring  it  about. 

Indications. — Obstetricians  differ  in  their  views  in  regard  to  the 
circumstances  that  call  for  such  a  wilful  interruption  of  the  pregnant 
condition,  and  sometimes  scientific  considerations  are  overshadowed 
by  religious  doctrines.  The  Roman  Catholic  Church  does  not  allow 
its  adherents  to  kill  a  human  fcetus  under  any  circumstances,  but 
from  a  scientific  and  humane  stand-point  the  operation  may  be  said 
to  be  indicated  when  on  account  of  narrowness  of  the  genital  canal 
a  viable  child  cannot  be  born,  or  when  the  mother's  health  is  such 
that  it  would  expose  her  to  death  or  dangerous  sickness  to  continue  in 
the  pregnant  state. 

The  first  indication,  that  based  on  mechanical  obstruction,  seldom 
occurs  in  this  country,  where  the  higher  degrees  of  pelvic  deformity 
are  exceedingly  rare.  Before  deciding  on  the  performance  of  artificial 
abortion,  the  patient  should  be  informed  of  her  chances  if  she  waits 
until  the  end  of  pregnancy  and  is  delivered  by  symphyseotomy  or 
Caesarean  section,  by  which  the  child's  life  may  be  spared. 

The  second  indication,  that  based  on  disease  in  the  mother,  is 
much  more  common.  Mere  unwillingness  to  increase  her  family, 
general  nervousness,  the  dread  of  supposed  dangers  of  childbed,  or 
the  painful  reminiscences  from  previous  experience  ought  not  for  a 
moment  to  be  considered  by  a  conscientious  practitioner.  But  as 
soon  as  well-ascertained  facts  in  her  past  or  the  presence  of  demon- 
strable serious  disease  makes  it  likely  that  the  patient  would  risk  her 
life  or  seriously  imperil  her  health  by  carrying  her  child  to  term,  it  is 
proper  for  the  physician  to  recommend  a  speedy  interruption  of  her 
pregnancy  and  for  the  obstetrician  to  perform  the  operation. 

Apart  from  acute  diseases,  the  character  of  which  becomes  more 
malignant  on  account  of  the  pregnancy,  conditions  that  justify  recourse 
to  artificial  abortion  are  especially  recent  syphilis,  advanced  pulmonary 
tuberculosis,  severe  valvular  heart  disease,  an  aneurism  of  the  aorta, 
carcinoma  that  has  gone  beyond  the  limits  of  radical  treatment,  chronic 

^  Garrigues,  "Artificial  Abortion,"  Trans.  Amer.  Gynaecol.  Soc,  1895,  vol. 
XX.  p.  469  ;  Amer.  Gynaecol,  and  Obstet.  Jour.,  June,  1895. 


270  ABNORMAL   PREGNANCY. 

nephritis,  serious  affections  of  the  nerve  centres,  and  present  or  threat- 
ened insanity. 

In  many  of  these  conditions  we  should  hesitate  the  less  to  destroy 
the  foetus  if  it  is  likely  to  inherit  the  mother's  disease, — e.g.  tubercu- 
losis, cancer,  or  syphilis. 

The  mere  presence  of  albuminuria  is  not  a  valid  indication  for 
artificial  abortion.  The  writer  has  successfully .  treated  numerous 
cases  of  this  kind  with  chloride  of  iron,  chloral  hydrate,  warm  baths, 
and  milk  diet,  even  when  decided  premonitory  symptoms  of  eclampsia, 
such  as  headache,  cardialgia,  vertigo,  and  dim  vision,  were  present. 
Albuminuria  should  be  looked  upon  as  an  indication  for  artificial  abor- 
tion only  when  the  condition  is  such  as  to  imperil  the  patient's  life. 

The  practitioner  should  also  be  very  loath  to  admit  vomiting  as  an 
indication  for  artificial  abortion.  By  patience  and  remedial  agencies 
the  pregnancy  can  with  few  exceptions  be  made  to  continue  to  term. 

Precautions. — No  one,  not  even  the  most  experienced  obstetrician, 
should  take  the  responsibility  of  performing  artificial  abortion  guided 
by  his  own  judgment  alone.  The  case  ought  to  be  submitted  to  one 
or  more  other  medical  men,  choosing  if  possible  the  consultants  in 
such  a  way  as  to  obtam  the  most  reliable  advice  according  to  the 
nature  of  the  condition  or  disease  calling  for  interference, — an  obste- 
trician in  cases  of  obstruction  in  the  genital  canal,  a  neurologist  in 
cases  of  insanity,  a  syphilologist  in  cases  of  syphilis,  a  man  with  wide 
medical  experience  in  cases  of  diseases  of  the  kidneys,  lungs,  or 
heart,  etc. 

The  outcome  of  the  consultation  should  be  put  in  writing,  signed 
by  the  consultant,  and  preserved  by  the  obstetrician  who  is  to  perform 
the  operation.  I  take  also  the  precaution,  if  possible,  to  acquire  the 
written  consent  of  the  patient  and  her  husband.  In  case  of  untoward 
symptoms  arising  after  the  operation,  or  of  a  fatal  issue,  these  docu- 
ments would  be  of  the  very  greatest  value  in  protecting  the  operator 
from  all  the  blame  which  the  patient  or  her  friends  often  lay  at  the 
door  of  the  man  who  has  been  only  actuated  by  the  purest  instincts 
of  humanity  and  the  most  approved  scientific  doctrines.  But  there 
is  little  or  no  danger  if  the  operation  is  properly  performed.  The 
troubles  we  read  about  in  the  newspapers  occur  only  at  the  hands  of 
professional  abortionists  or  physicians  who  for  lucre  comply  with  the 
wishes  of  patients  who  do  not  want  to  have  children. 

The  treatment  is  the  same  as  that  recommended  above  in  cases  of 
unavoidable  abortion, — rapid  dilatation,  curetting,  irrigation,  and  tam- 
ponade. 

§  4.  Criminal  Abortion. — Attempts  to  destroy  the  fetal  life  and 
cause  abortion  are  made  frequently  with  more  or  less  success.  Having 
exhausted  the  list  of  pills  and  medicines  that  have  a  reputation  for 


INTERRUPTION   OF   PREGNANCY.  271 

accomplishing  the  return  of  menstruation  without  attaining  their  aim, 
recourse  is  had  to  surgical  means.  Many  women  have  a  very  lax  con- 
science in  this  respect  and  feel  somewhat  shielded  by  the  old  theory 
of  quickening  as  the  beginning  of  life,  while  for  the  physiologist  and 
in  the  eyes  of  the  law  life  begins  from  the  moment  the  sexual  elements 
have  combined. 

The  women  themselves  poke  knitting-  or  crochet-needles  into 
their  genitals,  and  if  they  often  succeed  in  puncturing  the  ovum,  they 
also  sometimes  perforate  their  uterus  or  the  vaginal  vault,  causing 
serious  hemorrhage  or  a  septic  inflammation  of  the  pelvic  organs  that 
jeopardizes  their  lives.  Or  they  are  treated  by  doctors  and  midwives 
whose  transparent  advertisements  are  found  in  nearly  all  papers, 
especially  those  published  in  foreign  languages.  Although  the  laws 
concerning  criminal  abortion  are  very  severe,  these  persons  know  how 
little  likelihood  there  is  of  a  complaint  being  made,  and,  be  it  ignorance 
or  indifference,  they  expose  their  patients  to  the  greatest  dangers. 
They  go  so  far  as  to  introduce  a  sponge  or  laminaria  tent  and  let  the 
patient  walk  home  from  their  office,  or  in  their  eagerness  to  destroy 
the  foetus  with  the  uterine  sound  they  make  a  wound  in  the  uterus 
large  enough  to  admit  the  thumb  and  allow  the  intestines  to  protrude 
into  the  vagina. 

Respectable  physicians  when  called  to  see  patients  upon  whom 
other  persons  had  performed  abortion,  and  who  were  suffering  from 
hemorrhage  or  pelvic  inflammation,  have  sometimes  been  arrested 
by  suspicious  coroners  and  put  under  exorbitant  bail.  I  deem  it 
therefore  good  policy  in  all  such  cases  to  call  a  coroner's  physician 
in  consultation. 

§  5.  Premature  Labor. — Premature  labor  differs  from  abortion 
in  so  far  as  it  occurs  at  a  time  when  the  child  is  viable,  which,  as  we 
have  seen  above,  is  from  the  end  of  the  sixth  calendar  month.  The 
mother's  organism  approaches  also  the  condition  which  is  normal  at 
the  term  of  pregnancy  and  the  more  so  the  nearer  she  is  the  end  of 
gestation.  The  active  treatment  recommended  for  abortion  until  the 
end  of  the  fourth  month  would  therefore  not  only  be  out  of  place,  but 
positively  unnatural  and  dangerous,  especially  curetting.  In  fact,  in 
many  cases  the  whole  labor  is  very  much  like  that  at  term  and  should 
be  managed  as  such.  If  there  is  hemorrhage  and  no  dilatation  of  the 
cervix,  the  vagina  should  be  tamponed  and  the  tampon  renewed  every 
six  hours.  But  in  the  mean  time  the  heart  sounds  of  the  foetus  and 
the  mother's  general  condition  should  be  watched  carefully.  If  either 
mother  or  child  shows  signs  of  weakness,  it  is  better  to  dilate  the 
cervix  with  Hanks's  large  dilators  and  deliver  the  child.  If  the  placenta 
is  adherent,  it  is  best  to  pack  the  uterus  with  iodoform  gauze  and  the 
vagina  with  creoline  cotton  and  wait  for  a  day  or  two  in  the  hope 


272  ABNORMAL   PREGNANCY. 

that  its  connection  with  the  inside  of  the  uterus  may  become  loosened, 
but  at  the  end  of  that  time  it  must  under  all  circumstances  be 
removed  in  the  way  that  will  be  described  in  speaking  of  retention  of 
the  placenta  at  term.  If  the  premature  labor  is  combined  with  pla- 
centa praevia — the  insertion  of  the  placenta  over  the  internal  os — ^the 
sooner  the  uterus  can  be  emptied  the  better  it  is. 

If  the  child  is  born  much  too  early,  it  should  receive  all  the  care 
we  have  described  above  in  treating  of  congenital  weakness  (page 
254). 

§  6.  Induction  of  Premature  Labor. — Induction  of  premature 
labor  differs  from  artificial  abortion  by  being  undertaken  at  a  time 
when  the  child  is  viable  and  is  often  done  in  its  interest.  This  oper- 
ation is  based  on  the  observation  that  women  who  always  got  dead 
children  at  term  occasionally  gave  birth  to  a  living  child  if  they  hap- 
pened to  be  taken  in  labor  prematurely.  But  even  when  the  child  is 
dead,  the  operation  may  be  indicated  in  the  interest  of  the  mother. 
Performed  with  proper  antiseptic  precautions,  the  operation  is  without 
danger  for  her  and  it  may  save  her  life  or  give  her  great  comfort.  In 
so  far  as  the  child  is  concerned,  the  chances  for  its  survival  increase 
with  its  age.  Before  the  end  of  twenty-eight  weeks'  gestation  these 
are  so  small  that  it  would  be  senseless  to  operate  in  its  interest,  while, 
as  we  have  seen,  the  mother's  condition  may  be  such  that  we  even 
feel  warranted  in  interrupting  pregnancy  before  the  child  is  viable, 
and,  therefore,  much  more  so  when  there  is  a  possibility  of  saving  it. 
But  between  the  twenty-eighth  and  thirty-second  week  this  happy 
event  is  so  unlikely  that,  as  a  rule,  the  operation  should  not  be  under- 
taken. There  may,  however,  be  circumstances,  especially  in  regard  to 
inheritance,  under  which  the  parties  concerned  are  much  interested  in 
having  a  living  child,  even  if  it  should  not  live  long. 

Indications. — (1)  Narrow  pelvis  ;  (2)  diseases  of  the  mother ;  (3) 
the  habitual  death  of  the  foetus  ;  (4)  mother  dying ;  (5)  dead  child,  if 
labor  does  not  come  on  or  mother  is  suffering. 

Labor  may  be  induced  prematurely  in  moderate  degrees  of  pelvic 
contraction  both  in  the  interest  of  the  mother  and  in  that  of  the  child, 
the  mechanical  disproportion  being  less  marked  when  the  child  has 
not  reached  its  full  development.  The  earlier  the  operation  is  per- 
formed, the  more  the  passage  of  the  child  will  be  facilitated ;  but,  on 
the  other  hand,  the  later  we  operate,  the  greater  is  the  power  of 
resistance  of  the  child  and  consequently  the  chance  of  its  not  only 
being  born  alive,  but  of  surviving.  The  most  favorable  time  for  per- 
forming the  operation  is  at  the  end  of  the  thirty-sixth  week, — that  is, 
four  weeks  before  the  normal  end  of  pregnancy.  Before  the  end  of 
thirty-four  weeks  there  is  great  danger  of  subsequently  losmg  the 
child,  even  if  it  is  born  alive.     But  even  after  thirty-eight  or  forty 


INTERRUPTION    OF    PREGNANCY.  273 

weeks  it  may  be  advantageous  to  induce  labor,  in  order  to  prevent 
further  increase  in  size  of  the  foetus. 

The  degree  of  contraction  which  forms  the  Kmit  for  induction  of 
premature  labor  depends  on  the  size  of  the  head  which  has  to  pass 
through  the  pelvis.  The  most  common  kind  of  contracted  pelvis  is 
the  flat  pelvis,  in  which  the  true  conjugate  is  shortened.  In  this  form 
of  pelvis  the  head  has  to  pass  through  the  conjugate  with  one  of  its 
transverse  diameters,  the  bitemporal  or  the  biparietal  or  some  inter- 
mediate line  between  the  two.  Now,  measurements  of  a  number  of 
fetal  heads  have  shown  the  following  average  dimensions  (Ahlfeld) : 


V'eek  of  Pregnancy. 

32 

Biparietal  Diameter. 

(centimetres) 

7.85 

Bitemporal  Diameter. 

(centimetres) 
6.5 

33 

8.2 

7.1 

34 

8.0 

7.25 

35 

8.2 

36 

8.41 

7.2 

37 

8.45 

7.25 

38 

8.45 

7.25 

39 

8.47 

7.32 

40 

8.75 

7.52 

Schroeder  found  the  biparietal  diameter  even  somewhat  longer : 
in  the  eighth  luwar  month  8.16  centimetres,  in  the  ninth  8.69,  and  in 
the  tenth  8.83. 

Making  allowance  for  some  compressibility  of  the  head,  the  lowest 
limit  of  contraction  of  the  pelvis  in  which  premature  labor  should  be 
induced  is  therefore  when  the  true  diagonal  measures  seven  centi- 
metres, or  2|  inches. 

If  the  other  dimensions  of  the  pelvis  are  reduced,  no  general  rule 
can  be  formulated,  except  that  the  conjugate  then  must  be  propor- 
tionately longer. 

If  the  period  of  pregnancy  is  not  known,  we  are  reduced  to  a 
comparison  between  the  size  of  the  pelvis  and  that  of  the  head.  The 
true  conjugate  can  be  calculated  pretty  exactly,  but  direct  measure- 
ments of  the  head  through  the  abdominal  and  the  uterine  wall  are  far 
from  accurate.  The  experienced  obstetrician  derives  more  informa- 
tion by  grasping  the  head  as  described  above  (page  109),  and  forming 
an  opinion  about  its  size  in  relation  to  the  pelvis,  or  he  may  try  to 
press  it  down  into  the  pelvis,  or  simply  move  the  bent  knees  up  and 
down  and  feel  if  tlie  head  engages  in  the  brim  of  the  pelvis ;  as  long 
as  it  does  so  there  is  no  need  of  hurry. 

The  birth  of  a  living  child  in  cases  of  contracted  pelvis  depends  so 
much  on  the  size  of  the  head  and  the  degree  of  ossification  of  its 
bones  and  the  strength  of  uterine  contractions  that  it  is  diflicult  to 

18 


274  ABNORMAL   PREGNANCY. 

predict  with  certainty  that  a  hving  child  cannot  go  through  a  certain 
pelvis.  The  writer  has  repeatedly  seen  normal  confinements  at  term 
in  Avomen  in  whom  on  account  of  a  conjugate  reduced  to  three  inches 
he  anticipated  great  trouble.  As  a  rule,  it  is,  therefore,  better  not  to 
induce  premature  labor  for  pelvic  deformity,  unless  experience  in  one 
or  more  preceding  labors  has  shown  that  the  patient  cannot  give  birth 
to  a  living  child  at  term.  Exact  information  about  the  measurements 
and  condition  of  the  fetal  head  in  previous  confinements  is  of  the 
greatest  value  in  this  respect. 

Before  determining  to  induce  premature  labor,  the  accoucheur 
should  use  every  means  of  satisfying  himself  by  palpation  and  auscul- 
tation that  he  has  not  to  deal  with  twins  simulating  a  large  child.  If 
the  mother  is  so  seriously  ill  that  her  life  is  endangered,  and  there  is 
reason  to  believe  that  her  condition  will  be  much  improved  by  the 
termination  of  her  pregnancy,  the  induction  of  premature  labor  is 
justifiable,  even  with  some  risk  to  the  child.  Dyspncea  and  suffo- 
cating spells  occurring  in  consequence  of  pneumonia,  pulmonary  tu- 
berculosis, heart  disease,  nephritis,  or  hydramnion  are  the  chief  con- 
ditions that  call  for  the  premature  interruption  of  pregnancy.  If  the 
child  is  dead,  the  indication  for  bringing  relief  to  the  mother  is,  of 
course,  still  more  urgent. 

It  has  been  noticed  that  in  some  women  the  child  habitually  dies 
about  the  same  time  of  pregnancy,  and  that  its  life  may  be  saved  by 
induction  of  premature  labor.  In  such  cases  the  operation  should  be 
performed  shortly  before  the  term  at  which  death  occurred  in  previous 
pregnancies. 

If  the  mother  is  in  a  dying  condition  and  the  child  living,  it  is  our 
duty  either  to  be  prepared  to  perform  Csesarean  section  immediately 
after  her  death  or,  if  possible,  to  induce  premature  labor  before  she 
dies.  The  cutting  up  of  the  body  of  a  beloved  person  the  moment 
she  expires  has  something  so  harrowing  to  the  feelings  that  in  many 
cases  the  second  alternative  will  be  preferred,  even  in  spite  of  the 
unavoidable  addition  to  the  sufferings  of  the  dying  woman  and  with 
the  risk  of  hastening  her  death. 

We  have  already  mentioned  that  labor  should  be  induced  if  the 
child  is  dead  and  the  mother  in  a  condition  which  presumably  will  be 
improved  by  the  interruption  of  pregnancy.  If  the  mother  is  in  good 
condition,  but  labor  does  not  come  on  within  a  reasonable  time,  it  is 
better  to  induce  it.  If  the  child  is  alive,  we  thereby  avoid  its  further 
growth,  which  might  jeopardize  the  lives  of  both  mother  and  child, 
and  if  the  child  is  dead,  we  prevent  its  undue  retention  in  the  maternal 
body. 

§  7.  Hunger  Cure. — In  order  to  avoid  induction  of  premature 
labor  in  cases  of  moderate  coarctation  of  the  pelvis,  it  has  been 


MISSED   LABOR.  275 

recommended  to  put  the  mother  during  the  last  two  months  on  a 
special  and  somewhat  restricted  diet.  The  writer  has  tried  this  only 
once,  in  a  case  where  the  conjugate  measured  three  inches,  and  the 
result  was  perfect ;  but  the  same  lady  later  gave  birth  to  a  full-grown 
child  Avithout  keeping  to  this  diet.  There  have  come  many  favorable 
reports  from  other  observers  ;  but  complete  failures  have  also  occurred, 
and  we  see  poor  women  who  have  no  abundance  of  food  occasionahy 
give  birth  to  very  large  children.  The  diet  is  particularly  aimed 
against  the  production  of  fat,  but  the  difficulties  in  mechanical  dis- 
proportion arise  much  more  from  the  bones  than  from  the  fat  of  the 
child.  The  diet  recommended  consists  in  the  following :  For  break- 
fast, four  ounces  of  black  coffee  or  tea  and  one  ounce  of  zwieback  or 
toast ;  for  lunch  and  dinner,  a  sufficient  amount  of  beef,  mutton,  veal, 
pork,  game,  poultry,  eggs,  fish,  lobsters,  crabs,  shrimps,  crawfish, 
oysters,  clams,  scallops,  mussels,  green  vegetables,  lettuce  salad,  cheese, 
a  small  amount  of  juicy  fruit,  two  ounces  of  bread,  with  half  a  pint  of 
claret  or  Moselle  wine.  Butter  and  other  fats  are  harmless.  Forbid- 
den, on  the  other  hand,  are  soup,  water,  milk,  beer,  potatoes,  beets, 
cereals,  puddings,  pies,  and  other  sweet  dishes,  candy,  as  well  as 
bananas. 


CHAPTER    IV. 
MISSED   LABOR. 


Missed  labor  is  the  name  given  to  an  exceedingly  rare  event. 
At  the  time  labor  was  due,  either  it  does  not  begin  at  all  or  it  is 
ineffectual  and  soon  ceases,  the  foetus  remaining  in  the  uterus,  where 
it  may  stay  for  many  months  or  even  years.  As  a  rule,  the  waters 
break  and  drain  off,  and  microbes  enter  the  uterine  cavity,  causing 
putrefaction  of  the  foetus,  which  becomes  disintegrated,  and  is  elimi- 
nated piecemeal  either  through  the  os  or  through  openings  forming  in 
the  uterine  and  abdominal  walls.  Communication  with  the  intestine 
has  also  been  observed.  As  a  rule,  the  patient  is  carried  off  by 
exhaustion  and  septicsemia. 

Etiology. — The  cause  of  missed  labor  used  to  be  shrouded  in 
impenetrable  mystery.  Later  observers  have  repeatedly  found  exten- 
sive peritonitis,  but  the  question  remains  whether  this  is  the  cause  or 
the  effect  of  the  missed  labor.  If  it  is  the  cause,  perhaps  adhesions 
prevent  uterine  contraction  or  the  musculature  of  the  uterus  may 
undergo  fatty  degeneration.  In  one  case  the  uterine  wall  was  full  of 
myomas  that  had  undergone  fatty  degeneration. 

Treatment. — In  view  of  the  extremely  serious  prognosis,  every 
effort  should  be  made  to  dilate  the  cervix,  remove  the  fcEtus,  and 


276  ABNORMAL  PREGNANCY. 

wash  out  the  cavity  of  the  uterus  with  antiseptic  fluid.  When  fis- 
tulous tracts  have  formed  through  the  abdominal  wall,  it  may  be  pos- 
sible to  dilate  them  with  laminaria  tents  or  incise  their  surroundings 
sufficiently  to  give  exit  to  parts  of  the  foetus. 


CHAPTER    V. 
MISSED    ABORTION. 


Missed  abortion  forms  a  companion-piece  to  missed  labor,  but 
while  the  latter  is  one  of  the  rarest  occurrences  in  obstetrics,  the 
former  is  quite  common.  As  missed  abortion  we  designate  namely 
the  condition  in  which  early  in  pregnancy  the  foetus  dies  and  is  re- 
tained in  the  uterus,  which  it  may  be  for  many  months.  The  liquor 
amnii  is  absorbed,  and  the  foetus  dries  up  and  becomes  mummified. 

Treatment. — In  the  beginning  an  expectant  treatment  is  indicated, 
for,  as  a  rule,  abortion  will  follow  within  a  few  weeks.  But  if  there 
is  bleeding  or  any  other  undesirable  symptom,  the  uterus  should  be 
emptied,  as  described  in  the  chapter  on  abortion  and  premature  labor. 


CHAPTER    VI. 

DISEASES   OF   THE   GENITAL   ORGANS. 

§  1.  Malformations. — Embryology  teaches  us  that  the  uterus 
and  the  vagina,  as  well  as  the  Fallopian  tubes,  are  developed  from 
the  Muherian  ducts,  two  tiny  canals  that  extend  from  the  abdominal 
cavity  to  the  vulva.  That  part  of  the  Miillerian  ducts  that  lies  above 
the  round  ligament  of  the  uterus  remains  separate  from  that  of  the 
other  side,  and  forms  the  Fallopian  tube,  while  that  part  which  is 
situated  below  the  round  ligament,  together  with  the  lower  ends  of 
another  pair  of  tubes,  the  Wolffian  ducts,  which  extend  from  the 
Wolffian  body,  the  primitive  kidney,  to  the  vulva,  forms  a  quad- 
rangular cord  with  rounded  edges,  the  genital  cord  (Fig.  247). 

The  tissue  that  separates  the  two  Miillerian  ducts  is  gradually 
absorbed,  until  at  the  end  of  the  second  month  there  is  one  canal 
instead  of  two.  The  genital  cord  is  developed  so  as  to  form  the 
uterus  above  and  the  vagina  below.  While  the  fusion  of  the  Miillerian 
ducts  is  still  incomplete,  they  are  separated  above,  forming  the  two 
horns  of  the  uterus  (Fig.  248). 

About  the  middle  of  pregnancy  the  fetal  uterus  forms  one  sac 
without  horns. 

The  Miillerian  ducts  open  into  the  lower  part  of  the  urachus, — 


DISEASES   OF   THE  .  GENITAL   ORGANS. 


277 


that  is,  that  part  of  the  allantois  which  is  inckided  in  the  fetal  body, 
and  later  forms   the    bladder.     This    lower  part,   situate    below  the 


Fig.  247 


Transverse  sections  of  the  genital  cord  of  the  embryo  of  a  cow,  two  and  a  half  inches  long. 
Enlarged  fourteen  times.  (KoUiker.)  1,  from  the  upper  end  of  the  cord;  2,  somewhat  lower 
down ;  3,  4,  from  the  middle  of  the  cord,  showing  incomplete  and  complete  fusion  of  the  two  Miil- 
lerian  ducts  ;  5,  from  the  lower  end,  showing  the  Miillerian  ducts  separated,  o,  anterior  surface  of 
genital  cord  ;  p,  posterior  surface ;  w,  Miiller's  duct ;  lud,  Wolffian  duct. 

openings  of  the  Miillerian  and  the  Wolffian  ducts,  is  called  the  uro- 
genital sinus.  Originally  this  sinus  opens  into  the  cloaca.  Later  a 
septum  is  formed,  dividing  the 
cloaca  and  thereby  separating  the 
urogenital  sinus  from  the  rectum. 
The     urogenital     sinus     growing 

Fig.  248.  ^ 


Fig.  249. 


Ovaries,  tubes,  and  uterus  of  human  foetus 
from  the  tenth  week,  twenty-six  millimetres 
long.  (H.  Meyer.)  1,  natural  size;  2,  enlarged 
four  times,    a,  round  ligament;  6,  rectum. 


Urogenital  sinus  and  its  appendages  from 
human  embryo.  Life  size.  (Koelliker.)  1,  from 
a  three  months'  fcetus ;  2,  from  a  four  months' 
foetus  ;  3,  from  a  six  months'  ftetus.  b,  bladder; 
ur,  urethra ;  ug,  urogenital  sinus ;  g,  genital  canal 
(common  rudiment  of  vagina  and  uterus)  ;  v, 
vagina ;  ut,  uterus. 


much  less  than  the  other  parts,  especially  the  vagina,  in  course  of  time 
it  appears  as  the  continuation  of  the  latter  and  becomes  the  vestibule. 


278 


ABNORMAL    PREGNANCY. 


In  the  fifth  and  sixth  month  of  fetal  hfe  the  vagina  is  separated 
from  the  uterus  by  the  formation  of  a  ring  (Fig.  249). 

Bearing  in  mind  this  origin  of  the  uterus  and  the  vagina,  we  can 
easily  understand  the  different  malformations  of  tliese  organs,  which 
all  can  be  reduced  to  an  arrest  of  development,  Avhereby  the  growth 
or  the  fusion  of  the  Miillerian  ducts  becomes  defective.  Those  forms 
of  malformations  which  prevent  conception,  such  as  atresia  of  the 
genital  canal,  do  not  concern  us  here ;  but  there  are  others  that  are 
of  more  or  less  importance  to  the  obstetrician. 


Fig.  250. 


rterus  duplex  separatus,  or  uterus  rlidelphys.  (Nagel.)  1,  right  tube  ;  2,  right  ovary  ;  3,  right 
uterus,  in  which  the  tetus  was  developed  ;  4,  rectovesical  ligament ;  5,  left  ovary ;  6,  left  tube;  7, 
left  uterus  Avith  decidua  ;  8,  left  vagina  ;  9,  vaginal  septum  ;  10,  right  vagina. 

1.  Uterus  Duplex  Separatus,  or  Uterus  Didelphys. — This  variety 
of  uterus  is  produced  when  the  two  Miillerian  ducts  do  not  even  come 


DISEASES   OF   THE    GENITAL    ORGANS.  279 

in  contact  with  each  other  in  that  part  of  their  course  in  which  they 
usuahy  blend,  forming  the  uterus.  The  consecjuence  is  that  there  are 
two  entirely  separate  uteri,  but  each  of  them  represents  only  one-half 
of  the  total  organ.  Each  half  has  at  its  upper  end  a  Fallopian  tube 
and  a  round  ligament.  At  the  lower  end  the  double  cervix  opens 
into  a  single  or  double  vagina,  or  this  organ  may  be  more  or  less 
defective  (Fig,  250), 

In  the  Hving  woman  it  will  hardly  be  possible  to  distinguish  the 
uterus  clidelphys  from  the  two-horned  uterus  through  the  closed 
abdominal  wall,  but  the  writer  once  found  such  a  case  in  performing 
salpingo-oophorectomy. 

Tlie  prognosis  is,  as  a  rule,  good,  since  pregnancy  and  labor  may 
take  an  entirely  normal  course  ;  but  sometimes  the  second  uterus,  which 
usually  becomes  retroflexed,  has  offered  an  obstacle  to  the  birth  of  the 
child.  On  account  of  the  intimate  connection  between  the  two  parts 
of  the  uterus,  a  decidua  forms,  and  the  musculature  becomes  hyperplas- 
tic in  the  empty  half  as  well  as  in  that  occupied  by  the  foetus,  and  in 
twin  pregnancies  each  compartment  of  the  uterus  may  contain  a  foetus, 

2,  Uterus  Unicornis. — If  only  one  of  the  Miillerian  ducts  is  devel- 
oped while  the  other  is  absent  or  rudimentary,  the  result  is  a  one- 
horned  uterus  (Figs.  251,  252), 

The  one-horned  uterus  is  always  very  long,  forms  a  curve  with 
the  concavity  turned  outward,  and  ends  in  a  point  Avithout  a  fundus. 

Pregnancy  in  a  plain  unicorn  uterus  may  not  offer  any  peculi- 
arity, and  women  with  such  uteri  have  borne  many  children  without 
any  difficulty.  The  diagnosis  is  easier  in  the  unimpregnated  condition 
than  during  pregnancy,  the  peculiar  position  and  shape  being  rec- 
ognizable in  the  former  by  bimanual  and  rectal  examination,  while, 
when  the  uterus  develops  during  pregnancy,  it  may  be  much  like  a 
normal  uterus. 

But  attached  to  the  point  where  the  cervix  merges  into  the  body  of 
the  unicorn  uterus  is  sometimes  found  a  rudimentary  horn.  If  preg- 
nancy takes  place  in  this,  the  condition  is  a  very  grave  one,  the  rudi- 
mentary horn  being  incapable  of  producing  the  necessary  muscular 
tissue  to  form  a  sac  for  the  growmg  foetus.  The  situation  is  then 
practically  the  same  as  in  tubal  pregnancy,  from  which  it  cannot  be 
distinguished  clinically. 

As  a  rule,  pregnancy  ends  in  rupture  of  the  unprotected  fetal  sac, 
which  rupture  usually  occurs  between  the  third  and  sixth  months  of 
gestation,  and  is  fatal.  In  rare  cases,  however,  the  pregnancy  con- 
tinues until  term,  when  the  child  dies  and  by  calcareous  deposit  is 
changed  into  a  stony  mass  called  Uthopcedion,  Avhich  may  be  carried 
for  many  years  or  undergo  suppuration  and  disintegration  and  kill  its 
bearer  through  septicaemia. 


280 


ABNORMAL    PREGNANCY. 


Even  anatomically  the  examiner  may  be  led  into  error,  as  was 
the  case  with  regard  to  the  specimen  we  reproduce  in  Figs.  263  and 
264.  The  landmark  is  the  insertion  of  the  round  ligament.  A  tube, 
be  it  ever  so  narrow,  if  situated  inside  of  the  round  ligament,  is  a 
horn  of  the  uterus,  while  the  Fallopian  tube  starts  from  the  same 
point  as  the  round  ligament  and  extends  outward. 

An  ovum  may  develop  in  a  rudimentary  horn  that  has  no  com- 
munication with  the  other  horn  or  the  vagina.     This  may  be  brought 

Fig.  251. 


Left-sided  uterus  unicornis  with  gravidity  in  right  rudimentary  horn ;  rupture  in  the  sixth 
month.  (Observed  by  Tiedemann  and  Czihac,  revised  by  Kussmaul,  Mangel,  Verkummerung  und 
Verdopplung  der  Gebarmutter,  Wurzburg,  1859,  p.  111.)  a,  one-horned  uterus,  mostly  covered  with 
peritoneum  ;  6,  left  round  ligament ;  c,  left  tube  ;  d,  left  ovary  ;  e,  left  broad  ligament ;  /,  muscular 
band  connecting  the  left  horn  with  the  sac  containing  the  fcetus ;  g,  fetal  sac ;  h,  rupture  of  fetal 
sac  ;  i,  placenta  ;  k,  membranes  of  ovum  ;  I,  umbilical  cord  ;  m,  right  Fallopian  tube  ;  7i,  right  ovary  ; 
o,  rigiit  round  ligament,  radiating  into  fetal  sac  and  spreading  over  muscular  connecting  hand 
into  left  horn  ;  p,  limit  of  peritoneal  cover  of  fetal  sac ;  q,  vagina. 

about  in  one  of  two  ways, — either  the  fertilized  ovum  from  the  ovary 
corresponding  to  the  pervious  horn  is  by  external  migration  (p.  12) 
carried  over  to  the  fimbrise  of  the  other  tube  and  migrates  through 
this  to  the  cavity  of  the  closed  horn,  or  the  spermatozoids  may  in  a 
similar  way  wander  through  the  well-developed  horn,  the  correspond- 
ing tube,  the  abdominal  cavity,  and  the  tube  of  the  other  side,  which 
process  is  called  the  external  fiiigration  of  the  semen.  In  this  latter 
case  the  ovum  originates  in  the  ovary  corresponding  to  the  rudi- 
mentary horn. 


DISEASES   OF   THE   GENITAL   ORGANS. 


281 


Treatment. — The  treatment  is  the  same  as  for  tubal  pregnancy, 
from  which  it  cannot  be  distinguished.  During  the  first  three  or  four 
months  an  attempt  may  be  made  to  kill  the  foetus  with  a  strong  gal- 
vanic current.  But  in  our  days,  when  there  is  so  strong  a  tendency 
to  operative  interference,  most  obstetricians  will  be  in  favor  of  removal 
of  the  offending  horn  by  means  of  laparotomy — semi-ampidation  of 
the  gravid  uterus.  If  pregnancy  continues  beyond  the  fourth  month, 
there  is  hardly  any  other  way  than  the  latter,  which  also  is  indicated 
after  rupture  or  after  the  death  of  the  child;  but  while  the  prognosis 
for  the  operation  is  good  before  rupture,  it  is  nearly  desperate  after 
rupture  or  the  development  of  septicsemia.  In  the  latter  eventuality 
it  would  probably  be  better  to  perform  supravaginal  amputation  with 


Fig.  252. 


Longitudinal  section  through  the  same  specimen,  a,  cavity  of  the  left,  well-developed  horn  ;  6, 
cervical  canal;  c,  vagina;  dd,  decidua;  e,  top  of  left  horn,  continuous  with  the  Fallopian  tube; 
/,  muscular  connecting  band  ;  g,  cavity  of  a  rudimentary  right  horn  transformed  into  fetal  sac ; 
hh,  peritoneum  ;  ii,  muscular  tissue  with  innumerable  cut  blood-vessels ;  k,  placenta;  U,  membranes 
of  ovum  ;  m,  umbilical  cord  ;  n,  right  Fallopian  tube. 

external  treatment  of  the  stump  according  to  Porro,  which  will  be 
described  under  Caesarean  Section, 

3.  Uterus  Bicornis. — When  the  Mullerian  ducts  remain  more  or 
less  separated  from  each  other  in  that  part  of  their  course  which 
forms  the  uterus,  this  organ  appears  with  two  more  or  less  distinct 
horns  at  its  upper  end.  There  may  be  a  complete  partition  going  all 
the  way  down  to  the  external  os,  so  that  there  is  a  double  cervix  ;  or 
the  cervix  may  be  single ;  or  the  partition  may  be  absorbed  more  or 
less  high  up  between  the  two  horns,  until  it  is  represented  inside  only 
by  a  ridge  at  the  fundus,  while  on  the  outside  the  horns  are  sepa- 
rated only  by  a  corresponding  slight  depression  (uterus  arcuatus). 


282  ABNORMAL    PREGNANCY. 

Diagnosis. — The  presence  of  a  double  vagina  makes  it  likely,  but 
not  sure,  that  the  uterus  is  also  double.  If  the  cervix  is  also  double, 
the  likelihood  of  the  uterus  being  partitioned  becomes  still  greater, 
and  if  only  one  side  is  impregnated,  this  is  tilted  to  the  corresponding 
side  of  the  abdomen.  If  both  sides  contain  a  fcetus,  there  is  felt  a 
deep  furrow  extending  from  the  fundus  to  the  symphysis.  In  cases  . 
of  uterus  arcuatus  the  peculiar  shape,  especially  during  uterine  con- 
traction, may  be  felt. 

Prognosis. — The  prognosis  is  good  if  the  communication  is  free 
from  the  uterine  cavity  to  the  external  genitals  ;  but  if  the  impregnated 
horn  is  closed,  we  have  a  condition  similar  to  that  just  mentioned  in 
connection  with  the  one-horned  uterus  with  a  rudimentary  second 
horn.  The  prognosis  is  also  much  less  good  if  the  pregnancy  in  one 
horn  is  complicated  with  a  retention  of  menstrual  blood  in  the  other 
— hsematometra. 

Treatment. — In  most  cases  only  the  ordinary  management  of  normal 
labor  is  called  for.  In  a  case  of  pregnancy  in  a  closed  horn  laparot- 
omy and  amputation  of  this  horn  are  indicated.  In  complication  with 
hsematometra  and  heematocolpos,  it  may  become  necessary  to  make 
an  incision  in  the  partition  and  wash  out  the  accumulated  fluid  in 
order  to  give  room  for  the  passage  of  the  child. 

4.  Uterus  septus,  or  uterus  bilocularis,  is  a  uterus  with  a  normal 
outer  shape  but  with  a  complete  partition  between  the  two  halves, 
which  is  much  rarer  than  the  corresponding  bicornute  variety. 

If  the  septum  is  incomplete,  the  uterus  is  called  subseptus.  Preg- 
nancy may  occur  in  either  or  both  halves,  and  childbirth  take  its  normal 
course. 

The  presence  of  a  double  uterus  has  probably  given  rise  to  many 
cases  of  supposed  superfetation. 

§  2.  Inflammations. — Decidual  Endometritis. — Endometritis  may 
have  existed  before  pregnancy  began  or  developed  during  it.  The 
inflamed  condition  of  the  lining  membrane  of  the  womb  constitutes, 
however,  a  hinderance  to  conception,  the  tissue  being  less  fit  for  the 
nidation  of  the  ovum,  or  perhaps  the  spermatozoids  become  dete- 
riorated. If  pregnancy  occurs,  the  ovum  is  apt  to  slide  too  far  down 
before  it  is  embedded,  which  may  give  rise  to  placenta  prsevia,  or  the 
pregnancy  may  terminate  in  abortion.  The  inflamed  decidua  may 
also  form  too  close  a  connection  with  the  chorion,  so  that  the  placenta 
remains  adherent  when  after  the  birth  of  the  chfld  it  should  separate 
from  the  uterus. 

During  pregnancy  endometritis  may  develop  in  consequence  of 
maternal  syphilis,  gonorrhoea,  febrile  infectious  diseases,  or  Asiatic 
cholera.  The  inflammation  may  begin  simultaneously  with  concep- 
tion,— for  instance,  when  a  woman  becomes  infected  from  a  syphilitic 


DISEASES    OF   THE  GENITAL    ORGANS. 


283 


man  at  the  time  of  impregnation.  The  endometritis  may  also  be 
acquired  during  labor  by  infection  from  the  cervix,  and  is  then  char- 
acterized by  a  purulent  discharge  from  the  inside  of  the  womb. 

The  presence  of  acute  endometritis  is  proved  by  the  production 
in  the  decidua  of  areas  composed  of  or  infiltrated  with  small  round 
cells  (Fig.  253).  A  chronic  form  gives  rise  to  the  formation  of  tuber- 
cles or  polypi  on  the  surface  of  the  decidua — endometritis  tuberosa  and 
polyposa  (Fig.  254). 

The  reflexa  does  not  coalesce  with  the  vera  and  the  cervical  plug 
is  not  formed  or  it  is  washed  away.  Often  considerable  amounts  of 
a  watery  fluid  are  secreted  {hydroi-rhoea  gravidarum)^  which  either 
dribbles  away  or  accumulates  until  all  is  ejected  at  once,  which  often 
is  followed  by  abortion.  The  fluid  is  watery,  yellowish,  sometimes 
tinged  with  blood.     It  is  easy  to  distinguish  it  from  liquor  amnii.     It 


Fig.  253. 


^•i 


cr 


^..d 


Interstitial  inflammation  of  the  decidua.     (Emanuel.)    a,  wedge-shaped  infiltration  with  small 
round  cells ;  6,  enlarged  glands ;  c,  small  blood-vessels ;  d,  glands. 


contains  uterine  cells,  while  the  liquor  amnii  contains  lanugo  and 
large  cells  filled  with  fat.  Sometimes  there  is  a  discharge  of  san- 
guinolent  mucus,  pure  blood  (hemorrhagic  endometritis),  or  pus. 

Sometimes  cysts  form  in  the  decidua  (cystic  endometritis).  In  syphi- 
litic women  true  gummata  have  been  found  in  the  decidua.  In  the 
placenta  we  often  find  fibrous  connective  tissue,  forming  large  white 
patches.  The  decidua  may  become  much  hypertrophied,  so  as  to 
form  a  thick  layer  on  the  ovum,  or  be  retained  in  the  uterus  after  its 
expulsion,  forming  a  sac  that  subsequently  may  be  expelled  spontane- 
ously or  necessitate  artificial  removal  with  the  hand  or  the  curette. 

Frequently  women  complain  of  pain  in  tlie  uterus  during  preg- 
nancy, which  probably  most  of  the  time  is  due  to  endometritis. 


284 


ABNORMAL   PREGNANCY. 


Treatment. — ^We  cannot  do  much  during  pregnancy.  Opiates 
should  be  used  with  great  discretion,  in  order  not  to  create  a  habit. 
When  there  is  loss  of  blood,  the  patient  should  be  kept  quietly  in  bed 
and  have  the  treatment  recommended  for  preventable  abortion, — 
opium  suppositories,  fluid  extract  of  viburnum  prunifolium,  a  saline 
aperient,  and  cool,  bland  diet.  During  acute  inflammation  it  may 
become  necessary  to  apply  an  ice-bag  and  give  antipyretics.  But  if 
our  resources  are  limited  during  the  duration  of  pregnancy,  we  should 
treat  the  patient  according  to  the  rules  of  gynaecology  when  involu- 
tion is  terminated  and  before  a  new  impregnation  occurs.^ 

Fig.  254. 


Endoinetritis  tuberosa  and  polyposa.     (Bulius. ) 


Metritis. — ^The  inflammation  of  the  parenchyma  of  the  uterus 
occurs  rarely  during  pregnancy,  and  can  hardly  be  clinically  distin- 
guished from  endometritis.     The  treatment  is  the  same. 

Perimetritis. — The  inflammation  of  the  peritoneal  covering  during 
pregnancy  is  still  rarer  than  metritis.  The  treatment  is  the  same, 
only  opium  must  be  used  in  much  larger  doses  and  combined  with 
quinine.  Towards  the  end  of  pregnancy  the  induction  of  premature 
labor  is  indicated. 

Colpitis,  Vaginitis,  or  Elytritis. — As  we  have  seen  above,  there  are 
considerable  venous  congestion,  oedema,  and  formation  of  new  tissue 

'  See  Garrigues,  Text-book  of  Diseases  of  Women,  third  ed.,  pp.  432-435. 


DISEASES    OF   THE    GENITAL    ORGANS.  285 

in  the  vagina  during-  pregnancy,  and  some  degree  of  leucorrhoea  is  so 
common  during  tliis  condition  that  it  is  counted  among  the  signs  of 
pregnancy.  No  wonder,  therefore,  that  inflammation  of  the  mucous 
membrane  of  the  vagina  is  of  frequent  occurrence.  The  inflamma- 
tion may  be  simple  catarrhal,  granular,  gonorrhoeic,  or  emphysematous. 
In  the  simple  catarrhal  there  are  thickening  of  the  epithelium,  enlarge- 
ment of  the  papillte,  and  formation  of  heaps  of  small  round  cells 
under  the  papillae.  In  the  granular  form  a  similar  process  takes  place 
on  a  greater  scale,  forming  prominences  on  the  surface  varying  in  size 
from  a  millet-seed  to  a  lentil.  In  the  gonorrhoeic  form  the  gonococcus 
may  be  found  in  the  secretion  and  in  the  interior  of  the  epithelial 
cells,  or  even  in  the  mucous  membrane  and  submucous  tissue. 

Symptoms. — The  patients  complain  of  a  disagreeable  sensation  of 
heat  in  the  vulva  and  the  vagina.  They  have  pains  in  the  pelvis  and 
the  groins,  which  increase  by  walking  or  other  exercise.  They  have 
a  sensation  of  general  malaise,  and  the  pulse  and  temperature  may 
show  that  they  have  fever.  Micturition  is  accompanied  by  a  scalding 
sensation.  Defecation  may  also  be  painful.  The  vagina  becomes  so 
sensitive  to  touch  that  coitus  becomes  impossible  and  the  introduc- 
tion of  a  speculum  unbearable.  The  mucous  membrane  is  red  and 
swollen,  sometimes  covered  v^'ith  prominences  that  make  it  feel  like  a 
grater.  At  first  it  is  dry,  but  soon  it  is  covered  with  a  more  or  less 
abundant  discharge,  which  in  the  beginning  is  mucous,  then  muco- 
purulent, and  still  later  sometimes  becomes  a  thick  creamy  pus,  which 
may  be  mixed  with  blood.  In  other  cases  it  is  more  white  and  foam- 
ing. Sometimes  semi-solid  cheesy  masses  are  seen  protruding  from 
dilated  glandular  openings.  By  pressing  on  the  urethra  often  a  drop 
of  pus  can  be  brought  to  view.  The  inflammation  may  spread  to  the 
vulvovaginal  gland  and  cause  the  formation  of  an  abscess  in  this  organ. 

Prognosis. — The  simple  and  granular  colpitis  are  not  of  much 
importance  and  are  easily  cured.  Not  so  the  gonorrhoeal  form,  which 
may  give  rise  to  dangerous  inflammation  in  the  mother  during  the 
puerperium,  and  exposes  the  child  to  ophthalmia  and  blindness.  It 
is  also  more  obstinate  in  its  resistance  to  treatment. 

Treatment. — In  mild,  non-specific  cases  injections  of  a  pint  of  a 
solution  of  alum  or  borax  (a  teaspoonful  to  a  pint  of  lukewarm  water) 
twice  a  day  may  suffice.  If  the  patient  is  feverish  and  the  genitals 
are  very  tender,  she  should  stay  in  bed,  use  injections  and  affusions 
of  plain  lukewarm  water  or  flaxseed  tea,  have  a  saline  aperient,  and 
be  put  on  a  bland  and  scant  diet.  When  the  sensitiveness  is  some- 
what subdued  and  the  discharge  is  purulent,  injections  containing 
creolin,  lysol,  or  carbolic  acid  (from  |-  to  1  per  cent.)  should  be 
used.  If  the  disease  resists  this  milder  treatment,  the  author  has 
seen  prompt  effect  from  the  application  of  undiluted  tincture  of  iodine 


& 


286  ABNORMAL    PREGNANCY. 

to  the  whole  surface  of  the  vagina  two  or  three  times  a  week.  A 
2  per  cent,  solution  of  nitrate  of  silver  or  a  10  per  cent,  solution 
of  copper  sulphate  may  be  poured  into  a  tuJ^uliform  speculum  in- 
troduced into  tlie  vagina  and  moved  to  and  fi'o.  If  the  urethra  is 
affected,  it  should  be  touched  with  a  match  or  toothpick  wound  with 
absorbent  cotton  and  dipped  in  a  solution  of  nitrate  of  silver  (5 
per  cent.),  or  a  few  drops  of  the  same  may  be  injected  with  Fritsch's 

syringe  (Fig.  255),  a  hypo- 
FiG.  255,  dermic  syringe  to  which  is 

attached  a  tube  with  a  small 
bulb  at  the  end  and  per- 
forated   with    several    fine 

Fritsch's  urethral  sjTinge. 

holes. 

During  pregnancy  it  is  not  safe  to  inject  large  amounts — quarts 
or  gallons — of  fluid.  Bichloride  of  mercury,  which  is  so  efficacious 
in  gonorrhoeal  colpitis  in  the  unimpregnated  condition,  is  so  dangerous 
in  pregnancy  that  it  should  not  be  used.  On  the  other  hand,  there 
does  not  seem  to  be  any  danger  in  the  use  of  medicated  pledgets  in 
the  vagina,  so  that  those  who  prefer  the  tampon  treatment  to  injections 
in  gonorrhoea  may  safely  employ  it. 

Emphysematous  colpitis  was  first  described  under  the  name  of 
colpohyperplasia  cystica.  This  disease  is  particularly  connected  with 
pregnancy,  and  is  rarely  found  outside  of  it.  It  is  not  very  common. 
It  is  characterized  by  the  presence  in  the  upper  part  of  the  vagina  and 
on  the  vaginal  portion  of  the  uterus  of  numerous  translucent  pink, 
gray,  or  bluish,  soft  cysts  varying  in  size  from  a  millet-seed  to  a  hazel- 
nut. They  are  situated  superficially,  either  in  dilated  lymph-vessels 
or  in  the  surrounding  connective  tissue,  and  accordingly  they  are  lined 
vdth  endothelium  or  they  have  no  such  lining.  They  contain  a  serous 
fluid  and  often  gas.  Some  have  a  central  depression.  Sometimes  they 
give  a  cracklmg  sensation  like  an  emphysema.  When  the  cysts  are 
pricked,  the  gas  escapes  with  a  distinct  wheezing  sound,  and  the  cysts 
collapse.  The  disease  is  always  accompanied  by  a  profuse  vaginal 
discharge,  and  the  vagina  is  tender  to  touch.  Otherwise  the  condition 
does  not  give  rise  to  any  symptoms,  and  it  disappears,  as  a  rule, 
within  two  weeks  after  confinement.  The  gas  is  produced  by  bacillus 
emphysematosus,  which  can  be  isolated  and  cultivated.  No  treatment 
is  needed,  except  cleansing  injections  as  in  other  forms  of  colpitis. 

Mycotic  Colpitis. — Two  kinds  of  fungi  are  often  found  in  the 
vagina  of  pregnant  women, — leptothrix  vaginalis  and  didium  albicans. 
Leptothrix  consists  of  fine  undivided  threads  with  oval  spores. 
Oidium  (Fig.  256)  has  hau--like  branches.  It  is  the  same  fungus  as 
the  one  forming  the  thrush  in  the  mouth  of  the  new-born. 

Leptothrix  hardly  gives  rise  to  any  symptoms.     Oidium  causes 


DISEASES    OF   THE    GENITAL    ORGANS. 


287 


sometimes  intense  pruritus,  burning,  swelling,  catarrhal  discharge,  and 
even  fever.     The  disease   may  end  in  a  few  days,  or  continue  for 
weeks   or  months.     The  mucous  membrane  of  the 
vagina  is  red,  tender,  and  studded  with  little  Avhite  Fig.  256. 

spots,  which  can  only  be  removed  together  with  the      I 
epithelium,  and  under  the  microscope  prove  to  he      1 1  q 

composed  of  hyphae  and  spores. 

The  fungi  may  be  brought  directly  into  the  vagina 
by  coition  with  men  affected  with  diabetes  mellitus, 
a  disease  in  which  they  frequently  are  found  between 
the  prepuce  and  the  glans.  They  may  also  be  car- 
ried in  by  fmgers  which  have  handled  flour,  such 
as  those  of  millers  and  bakers.  The  disease  can, 
as  a  rule,  easily  be  cured. 

Besides  the  injections  mentioned  above,  those 
with  sulphate  of  copper,  permanganate  of  potassium 
(1  or  2  per  cent.),  salicylic  acid  (1  or  2  per  thou- 
sand) are  recommended  in  this  particular  form  of 
colpitis. 

Another  organism  often  found  in  the  vaginal 
secretion  of  pregnant  women  is  the  trichomonas  vagi- 
nalis, an  infusorium  that  is  somewhat  like  a  mucus- 
corpuscle,  but  has  a  long  tail,  and  is  covered  with 
cilia  (Fig.  257).     It  is  without  clinical  importance. 

iED(EiTis. — The  inflammation  of  the  vulva  is 
mostly  combined  with  that  of  the  vagina,  and  is  quite 
common.  The  mucous  membrane  is  red,  swollen, 
and  covered  with  mucopurulent  secretion.    There  is 

I-  e    r.       I  J  •  •    n  it  Oidium    albicans. 

a    sensation   ot    heat  and  pam,   especially    scalding    (Haussmann.)    i,  ii, 
during  micturition.     The    groins    may   become  the    thread-shaped  form; 

c  o  J  III,  yeast-shaped  form. 

seat  of  intertrigo,  and  the  upper  part  of  the  inner 
surface  of  the  thighs  may  become  eczematous.  Intolerable  itching 
harrows  the  patient,  prevents  sleep,  and  may  drive  her  to  masturbation. 
Gonorrhceal  aedoeitis  is  much  like  simple  ca- 
tarrhal, but  redness  and  swelling  are  more  intense, 
the  discharge  is  more  purulent,  the  inflammation 
lias  a  tendency  to  impHcate  the  urethra,  and  bacteri- 
ological examination  may  show  the  presence  of  the 
gonococcus  of  Neisser. 

In  regard  to  prognosis,  the  reader  is  referred  to 
what  has  been  said  under  colpitis,  and  the  treat- 
ment is  also  much  the  same,  with  some  additions.     Lukewarm  sitz- 
baths  may  be  used  to  advantage  two  or  three  times  a  day.     For  the 
intertrigo  a  mixture  of  zinc  oxide  with  three  parts  of  corn-starch  is  the 


Fig.  257 


Trichomonas  vaginali: 
(Hanssmann.) 


288  ABNORMAL  PREGNANCY. 

best,  and  for  the  eczema  either  the  unguentum  diachylon  of  the  phar- 
macopoeia, or,  preferably,  the  following  modification  : 

R    Plumbi  oxidi,  1  part  ; 
01.  olivra,  3  parts  ; 
Aquae,  4  parts  ; 

which  ingredients  are  boiled  over  a  slow  fire  to  the  consistency  of 
thick  cream  of  salmon  color.  It  is  rubbed  into  the  skin  morning  and 
evening. 

§  3.  Pruritus  vulvae  is  frequent  in  pregnant  women.  It  is  char- 
acterized by  an  itching  sensation  on  the  inner  or  outer  surface  of  the 
vulva,  sometimes  extending  into  the  vagina  or  over  the  lower  half  of 
the  abdomen.  It  may  be  due  to  ^doeitis,  but  is  also  found  indepen- 
dently of  inflammation.  Sometimes  the  cause  is  direct  irritation  by 
parasites, — lice  or  itch-mites, — acrid  discharge  from  the  vagina,  or 
urine  containing  sugar,  for  which  proper  tests  should  be  used,  espe- 
cially boiling  with  Fehling's  solution,  the  copper  in  which  is  precipi- 
tated by  sugar. 

Treatment. — First  of  all  we  should  try  to  find  a  special  cause  apart 
from  the  pregnant  condition,  and  then,  if  possible,  remove  it.  If 
there  are  crab-lice  among  the  hairs  of  the  mons  Veneris,  these  should 
be  cut  or  shaved  off,  and  the  skin  smeared  with  blue  ointment  or 
painted  with  balsam  of  Peru,  or  w^ashed  with  a  strong  solution  of 
corrosive  sublimate  (1  grain  to  alcohol  and  water,  aa  §ss).  If  the 
acarus  scabiei  is  the  offender,  which,  fortunately,  is  rare  in  this  coun- 
try, we  should  try  to  exterminate  it  with  beta-naphtol  in  vaseline 
(gr.  XXV  to  §i),  or  sulphur  ointment ;  but  sometimes  a  general  treat- 
ment for  itch  of  the  whole  body  may  be  needed.  Since  this  is  rather 
harsh,  it  is,  however,  better  to  postpone  it  until  after  the  puerperium. 

Inflammation  of  the  vulva  and  vagina  should  be  treated  as 
described  above.  Pin-worms  are  removed  from  the  rectum  by 
extractum  sennse  et  spigelife  fluidum  (gss  t.  i.  d.  by  the  mouth)  or 
rectal  injections  of  an  infusion  of  quassia  (sii  to  Oj).  Hemorrhoids 
should  be  kept  in  check  with  unguentum  gallae  or  similar  substances. 
Glycosuria  should  be  treated  according  to  the  rules  of  practice  of 
medicine,  remembering,  however,  that  strychnine,  being  liable  to  cause 
abortion,  is  contraindicated  in  pregnancy. 

The  diet  is  of  great  importance.  Besides  following  the  special 
rules  for  diabetes  or  gout,  alcoholic  drinks,  strong  coffee,  and  spiced 
food  should  be  avoided.  The  food  should  be  nourishing,  but  bland. 
Milk  in  large  quantities — two  or  three  quarts  a  day — is  to  be  recom- 
mended, if  it  can  be  digested.  If  it  causes  dyspepsia  in  its  natural 
state,  it  should  be  tried  boiled,  skimmed,  or  peptonized. 

The   general   treatment  should  be  tonic,  sedative,  and  narcotic. 


DISEASES   OF   THE  GENITAL   ORGANS.  289 

Arsenic  and  quinine  are  particularly  recommended.  Bromide  of  po- 
tassium in  large  doses  (si-oii — from  4  to  8  grammes — daily)  is  often 
very  valuable.  Tinctura  cannabis  Indicse  (gtt.  xx  to  xl — -from  120  to 
250  centigrammes — t.  i.  d.)  is  preferable  to  opium  for  combating  pain. 
It  may  be  necessary  to  procure  sleep  by  means  of  chloralamid  sul- 
phonal,  urethane,  trional,  or  other  modern  hypnotics. 

The  local  treatment  is  not  less  important.  On  account  of  the 
pregnancy,  only  small  amounts  of  injection  fluid  should  be  used.  The 
routine  treatment  of  the  writer  is  to  prescribe  vagmal  injections  of 
carbolic  acid  (a  teaspoonful  to  a  pint),  to  paint  the  whole  mucous 
membrane  of  the  vulva  two  or  three  times  a  week  with  a  solution  of 
nitrate  of  silver  (from  5  to  8  per  cent.),  and  let  the  patient  keep  the 
labia  separated  by  means  of  fine  rags — for  instance,  pieces  of  an  old 
pocket  handkerchief — dipped  in  the  following  mixture  : 

R  Acidi  hydrocyan.  dil.,  gii  (8  grammes)  ; 
Plumbi  acetat. ,  ^ii  (260  centigrammes)  ; 
Glycerini,  q.  s.  ad  gii  (60  grammes)  ; 

and  changed  five  or  six  times  a  day.  Other  combinations  that  may 
be  useful  are — 

R    Ghlorali  hydrat. ,   3  i-ii  (4-8  grammes)  ; 
A''aselini  albi,   ^ii  (60  grammes). 

R   Ghlorali  hydrat., 

Gamphorse,  aa  ji  (4  grammes)  ; 
Vaselini  albi,   ^ii  (60  grammes). 

R    Ghlorali  hydrat., 

Gamphora?,  aa  3;ii  (8  grammes)  ; 
Acidi  oleici,  q.  s.  ad  ^ii  (60  grammes). 

R    Chloroformi,   gii  (8  grammes)  ; 
Vaselini  albi,   §n  (60  grammes). 

A  tampon  soaked  in  equal  parts  of  sulphurous  acid  and  glyceratum 
boracis  may  be  introduced  several  times  a  day  into  the  vagina. 

§  4.  Tumors. — Vegetations,  venereal  warts,  or  condylomata  acu- 
minata are  a  kind  of  papillomas,  which  are  frequently  observed  during 
pregnancy.  They  are  especially  common  in  patients  affected  with 
gonorrhcea,  but  may  also  appear  in  patients  who  have  no  other  affec- 
tion of  the  genitals,  and  are  then  due  to  lack  of  cleanliness.  Their 
most  common  seat  is  on  the  fourchette,  at  the  vaginal  entrance,  and 
on  the  labia  minora  and  majora ;  but  they  may  extend  through  the 
whole  vagina  and  to  the  vaginal  surface  of  the  vaginal  portion  of 
the  uterus,  the  inside  of  the  thighs,  and  around  the  anus.  On  the 
mucous  membrane  they  are  soft ;  on  the  skin  they  are  harder.  They 
begin  as  small  erosions,  which  soon  change  to  pin-head  sized  granular 

19 


290 


ABNORMAL    PREGNANCY. 


papules.  After  that  they  grow  rapidly,  forming  sessile  or  pedunculated, 
club-  or  coxcomb-shaped  protuberances.  Their  color  varies  much : 
some  are  light  gray,  others  are  pink,  dark  red,  or  purplish.  They  xary 
in  size  from  a  hemp-seed  to  a  raspberry  ;  but  if  neglected,  the  different 
isolated  growths  come  in  contact  with  one  another,  and  may  form  a 
tumor  as  large  as  the  fetal  head  (Fig.  258).  Their  surface  shows  always 
protuberances  separated  into  smaller  cauliflower-like  parts  springing 
from  a  narrow  base.  They  exhale  a  mucoid  secretion  of  a  sickening 
odor.     Even  the  drj^  vegetations  on  the  skin  are  apt  to  become  eroded 

Fig.  258. 


Vulvar  vegetations.    (Taruier  and  Budin,  1.  c.) 


and  secrete  such  fluid.  The  acrid  secretion  may  cause  colpitis  and 
aedoeitis,  and  the  tumors  may  mechanically  obstruct  the  meatus  uri- 
narius,  the  entrance  to  the  vagina,  and  the  anus,  so  as  to  interfere 
with  micturition,  coition,  defecation,  and  childlDirth.  When  they  are 
destroyed,  new  ones  are  very  prone  to  spring  up.  The  secretion,  if 
carried  into  the  eyes,  is  apt  to  cause  purulent  ophthalmia.  During 
childbirth  there  is  the  same  danger  of  infection  for  the  eyes  of  the 
child  and  of  puerperal  infection  for  the  mother. 

Diagnosis. — Flat   and    broad   vegetations    may   simulate    mucous 
patches ;  but  with  these  we  have  a  history  of  syphilitic  infection,  and. 


DISEASES    OF    THE    GENITAL    ORGANS.  291 

as  a  rule,  other  concomitant  symptoms  of  syphilis.  Mucous  patches 
are  few  in  number  and  develop  more  slowly. 

Treatment. — When  small  in  size,  vegetations  may  be  destroyed  with 
licjuor  antimonii  chloridi,  corrosive  sublimate  collodion  (.^ss  to  si — 
2  grammes  to  30  grammes),  salicylic  acid  dissolved  in  collodion 
(gi  to  51 — 4  grammes  to  30  grammes),  glacial  acetic  acid,  or  lactic, 
nitric,  or  chromic  acid.  The  tincture  of  thuya  orientalis  is  praised  as 
a  specific  for  these  tumors,  which  should  be  constantly  moistened 
with  it.  An  aqueous  solution  of  tannin  of  the  consistency  of  syrup, 
alum  powder,  ecpal  parts  of  calomel  and  salicylic  acid,  or  liquor  ferri 
chloridi  makes  them  shrink. 

If  the  tumors  are  of  medium  size — up  to  an  inch  in  diameter — 
they  may  be  tied  off  with  silk  or  rubber  thread.  If  they  are  still 
larger,  the  galvanocaustic  wire,  with  low  heat,  or  Paquelin's  thermo- 
cautery, is  the  best  means  for  their  removal. 

It  is  not  safe  to  cut  them  off  with  knife,  scissors,  or  cold  wire 
snare,  as  one  might  meet  with  a  hemorrhage  hard  to  arrest. 

Besides  the  medical  and  surgical  treatment  great  cleanliness  should 
be  inculcated.  Vaginal  douches  and  vulvar  affusions,  as  well  as  hot 
sitz-baths,  should  be  used  several  times  a  day. 

Varicose  Veins. — The  veins  of  the  vulva,  especially  the  labia 
majora,  may  swell  so  in  consequence  of  pressure  of  the  child  against 
the  pelvic  veins  as  to  form  tumors  of  considerable  size,  even  that 
of  the  fetal  head.  The  swollen  veins  form  dark  blue,  nearly  black, 
globular,  oval,  or  serpentine  soft  swellings,  that  collapse  on  pressure 
and  refill  immediately  when  the  pressure  is  discontinued.  They 
increase  as  pregnancy  progresses,  and  grow  smaller  after  the  birth  of 
the  child ;  but  often  they  do  not  disappear  altogether.  They  cause 
an  uncomfortable  sensation  of  heat  and  heaviness,  and  sometimes 
pruritus.  They  may  burst  spontaneously,  but  usually  that  accident  is 
due  to  injury  or  the  passage  of  the  child's  head.  If  the  skin  holds,  a 
subcutaneous  haematoma  is  formed ;  if  it  breaks,  a  serious  and  some- 
times fatal  hemorrhage  follows. 

Similar  varicosities  are  also  found  on  the  lower  extremities  and 
around  the  anus  of  pregnant  women. 

Treatment. — The  patient  should  be  directed  to  rest  in  a  recumbent 
position  in  the  middle  of  the  day  for  at  least  an  hour,  and  she  may 
even  manually  push  the  uterus  up,  in  order  to  relieve  the  pressure 
of  the  child  against  the  pelvic  veins.  At  times  complete  rest  in  bed 
or  on  a  lounge  is  indicated.  Fomentations  with  a  lead-and-opium 
wash  relieve  tension  and  heat.  A  pad  may  be  adapted  with  a  spica 
in  such  a  way  as  to  exercise  steady  compression.  The  leg  should 
be  covered  with  a  rubber  bandage,  for  which  after  confinement  may 
be  substituted  an  elastic  stocking.     The  patient  should  be  warned 


292  ABNORMAL    PREGNANCY. 

against  the  danger  of  hemorrhage,  and  taught  how  to  check  it  by 
compression  until  slie  can  get  help.  When  a  rupture  has  taken  place 
and  the  blood  escapes,  the  hemorrhage  should  be  controlled  by  means 
of  deep  sutures  and  an  effectual  outer  pressure  exercised  with  a  towel 
rolled  into  a  hard  cylinder  and  kept  in  place  with  a  rubber  bandage. 
To  plug  the  vagina  might  cause  abortion. 

Hemorrhoids. — The  same  internal  pressure  that  causes  varicose 
veins  in  the  labia  and  the  legs  produces  frequently  hemorrhoidal 
tumors,  wliich  may  cause  considerable  distress.  They  should  be 
bathed  with  a  sponge  or  pad  dipped  in  hot  water  and  smeared  with 
an  ointment  made  of  unguentum  gall*,  gi,  and  pulvis  opii,  gss,  and 
they  should  be  reduced  as  soon  as  possilDle. 

HEMATOMA,  OR  THROMBUS,  is  a  swelHug  due  to  extravasation  of 
venous  blood  in  the  connective  tissue  of  the  vulva.  It  is  most  com- 
mon in  the  labium  majus,  and,  as  a  rule,  only  one  side  is  affected. 
Varicose  veins  predispose  to  it.  The  exciting  causes  are  external 
violence,  such  as  a  blow,  a-  kick,  or  a  fall,  and  straining,  especially 
during  childbirth. 

The  haematoma  may  consist  in  a  small  swelling  of  the  size  of  a 
hazel-nut  or  acquire  the  dimensions  of  a  fist  or  a  fetal  head  at  term. 
It  is  of  dark  blue  or  purple  color,  and  tender  on  pressure.  The  blood 
may  become  absorbed,  or  suppuration  and  even  gangrene  may  set  in. 
When  the  tumor  becomes  inflamed,  swelling,  tenderness,  and  heat 
increase,  the  skin  takes  a  brighter  purple  color,  the  temperature  rises, 
the  pulse  becomes  full  and  frequent,  and  symptoms  of  septicaemia 
may  develop.  The  swelling  may  interfere  with  micturition  or  child- 
birth. It  may  also  burst,  causing  the  dangerous  hemorrhage  just 
mentioned.  As  a  complication  of  dehvery  it  has  proved  fatal  in 
twenty  per  cent,  of  cases  reported. 

Treatment — A  small  hgematoma  may  be  let  alone  or  treated  with 
cold,  astringent  or  absorbent  fomentations  (ice-bag,  ice- water  coil,  lead- 
and-opium  wash,  arnica).  If  it  is  larger  than  a  fist,  it  should  at  once 
be  opened  with  a  long  incision,  blood-clots  turned  out,  bleeding  arrested 
with  sutures  or  forcipressure,  and  the  cavity  packed  with  iodoform 
gauze  or  styptic  cotton.  As  soon  as  pus  is  formed,  the  haeinatoma 
should  under  all  circumstances  be  opened  and  thoroughly  disinfected. 

Myoma  of  the  Uterus. — Fortunately,  most  women  with  myomatous 
tumors,  so-called  fibroids,  in  their  uterus  are  sterile,  and,  if  they  con- 
ceive, their  pregnancy  quite  commonly  ends  in  abortion  or  premature 
labor.  Labor  at  term  may  be  easy,  but  oftener  the  fibroid  proves  a 
dangerous  complication.  All  depends  upon  the  size  and  the  situation 
of  the  tumor.  A  small  tumor  in  the  upper  part  of  the  uterus  is  of  no 
importance,  but  if  it  is  large  or  so  situated  as  to  encroach  materially 
upon  the  parturient  canal,  especially  the  cervix,  it  interferes  with 


DISEASES    OF    THE    GENITAL    ORGANS.  993 

the  development  or  expulsion  of  the  fetus.  During  pregnancy  the 
myoma  increases  in  size  and  softens.  After  labor  it  becomes  again 
smaller,  and  may  disappear  altogether.  Women  afflicted  with  myo- 
matous tumors  of  the  uterus  should  not  marry.  If  they  become 
pregnant,  it  is  in  harmony  "with  nature's  own  method  to  induce  abor- 
tion or  premature  labor,  whenever  the  tumor  is  situated  in  such  a 
place  or  has  such  dimensions  that  great  trouble  may  be  anticipated 
by  allowing  gravidity  to  go  on  till  full  term. 

To  operate  for  the  removal  of  the  myoma  during  pregnancy  will 
be  likely  to  lead  to  miscarriage.  Unless  there  are  urgent  symptoms 
demanding  immediate  attention,  such  as  liemorrhage  or  pressure  on 
the  pelvic  organs,  it  is  better  to  delay  operative  interference  until  labor 
sets  in.  After  the  end  of  the  puerperium  the  question  as  to  enuclea- 
tion or  hysterectomy  or  other  treatment  will  present  itself. 

Diagnosis. — Pregnancy  may  be  simulated  by  a  myoma,  and  the 
diagnosis  is  not  always  easy.  As  a  rule,  menstruation  stops  during 
pregnancy,  while  in  cases  of  myoma  it  goes  on  or  is  even  increased 
in  amount  and  duration.  The  development  is  regular  and  more  rapid. 
The  cervix  and  lower  uterine  segment  become  soft,  the  fluid  in  the 
fetal  sac  gives  a  peculiar  sensation  of  tense  elasticity,  and  ballottement 
may  be  elicited.  The  fetal  heart-sound  may  be  heard  and  fetal  move- 
ments heard,  felt,  and  seen.  A  point  of  great  value  is  the  contrac- 
tility of  the  gravid  uterus,  which  may  be  made  more  marked  by 
dipping  the  palpating  hand  in  ice-water.  Tlie  uterine  souffle  is  of  less 
importance,  since  it  maybe  found  with  myomas.  Nor  is  the  presence 
of  milk  in  the  breasts  conclusive.  The  writer  has  seen  milk  produced 
in  a  virgin  by  an  intra-uterine  injection  of  diluted  lic|uor  fern  chloridi 
to  check  hemorrhage  from  a  myoma. 

The  diagnosis  becomes  particularly  difficult  if  the  two  conditions 
are  combined,  and,  as  we  have  seen,  the  detection  of  such  a  compli- 
cation of  pregnancy  may  be  of  great  practical  importance  in  regard 
to  the  treatment  to  be  adopted.  A  suspicion  of  such  a  coincidence 
should  be  awakened  by  hemorrhages  occurring  during  pregnancy. 
The  use  of  the  uterine  sound  is,  of  course,  not  available.  The  ob- 
stetrician must  rely  on  the  history  of  the  case,  the  auscultation,  and  a 
very  accurate  palpation. 

Sarcoma  and  Carcinoma  of  the  Uterus. — These  are  promiscuously 
called  cancer,  but  there  is  a  fundamental  difference  in  their  anatomical 
structure,  the  first  being  composed  of  round  or  spindle-shaped  cells, 
the  latter  of  polyhedral  epithelial  cells  arranged  in  alveoli  separated 
from  one  another  by  walls  of  connective  tissue.  Sarcoma  rarely 
attacks  the  cervix,  and  is,  therefore,  of  less  importance  to  us  as  ob- 
stetricians than  carcinoma,  which  has  a  predilection  for  that  organ. 
Both  undermine  the  constitution,  and  sooner  or  later,  in  most  cases 


294  ABNORMAL    PREGNANCY. 

within  a  few  years,  lead  to  deatli.  If,  furtliermore,  we  take  into  con- 
sideration that  they  may  offer  an  unsurmountable  obstacle  to  delivery 
and  that  the  foetus  may  inherit  the  tendency  to,  perhaps  even  the  germ 
of,  the  disease  from  the  mother,  there  is  only  one  thing  to  do  when  we 
find  cancer  of  the  uterus  in  a  pregnant  woman.  In  this  case  it  is  not 
sufficient  to  sacrifice  the  foetus.  If  we  find  the  uterus  in  such  a  con- 
dition that  a  radical  operation  is  still  possible,  especially  when  com- 
bined abdominal,  vaginal,  and  rectal  examination  shows  that  there  is 
no  swelling  of  the  broad  ligaments  and  the  womb  is  freely  movable, 
total  extirpation  should  be  done  at  once. 

The  form  of  cancer  with  which  the  obstetrician  most  frequently 
has  to  deal,  either  during  pregnancy  or  during  labor,  is  carcinoma  of 
the  cervix.  According  to  the  period  of  pregnancy  in  which  the  cases 
come  under  observation,  we  may  distinguish  three  groups,  which  offer 
different  indications  for  treatment.    " 

The  first  group  comprises  the  cases  in  which  the  unopened  and 
unemptied  uterus  can  be  extirpated  from  the  vagina  in  the  same  way 
as  a  non-pregnant  uterus.^  This  can,  as  a  rule,  be  done  without  special 
difficulty  until  the  end  of  the  fourth  month,  and  has  even  been  done 
in  the  fifth  and  sixth.  If  the  disease  has  spread  too  far  to  allow  extir- 
pation, a  palliative  operation,  including  abortion,  should  be  performed.^ 

The  second  group  is  composed  of  most  of  the  cases  that  are  in 
the  fifth,  sixth,  and  seventh  month.  The  uterus  is  too  large  to  pass 
through  the  vagina  while  it  contains  the  foetus.  Under  these  circum- 
stances different  operations  are  available  : 

First. — Abortion  or  premature  labor  may  be  induced,  and  as  soon 
as  the  uterus  is  empty  it  is  removed  by  vaginal  section. 

Second. — The  whole  uterus  may  be  removed  by  abdominal  sec- 
tion, but  this  involves  great  danger  of  infecting  the  peritoneal  cavity 
with  cancer  germs,  even  if  the  cervix  is  curetted  and  cauterized  before 
the  operation. 

Third. — It  is  better  to  perform  supravaginal  amputation  and  sub- 
sequently extirpate  the  cervix  from  the  vagina. 

Fourth. — Both  the  foetus  and  the  uterus  may  be  removed  through 
the  vagina. 

If  the  cancer  is  not  operable  and  the  child  is  near  the  period  of 
viability,  we  may  wait  a  short  time  so  as  to  give  it  a  chance ;  but  if 
hysterectomy  can  be  performed,  it  ought  to  be  done  at  once,  without 
regard  to  the  child,  for  the  carcinomatous  degeneration  spreads  rapidly 
during  pregnancy. 

The  third  group  encompasses  the  time  when  the  child  is  viable. 
If  the  child  is  viable  and  the  carcinoma  operaJole,  it  is  best  to  perform 

^  Gamgues,  Diseases  of  Women,  third  ed.,  pp.  510-515. 
2  Ibid.,  p.  543. 


DISEASES    OF   THE    GENITAL    ORGANS.  295 

conserv^ative  Caesareaii  section,  close  the  uterus,  tie  the  ovarian  ves- 
sels, and  then  extirpate  the  empty  uterus  from  the  vagina. 

If  the  child  is  viable  but  the  cancer  not  fit  for  a  radical  operation, 
the  cervix  should  be  curetted  and  cauterized,  and  thereafter  the  woman 
delivered  by  Cpesarean  section. 

If  the  case  does  not  come  under  observation  before  labor  has 
begun  and  the  cancer  is  operable,  it  may  be  possible  to  deliver  a  living 
child  per  vias  naturales,  either  by  means  of  a  high  forceps  operation 
or  podalic  version  followed  immediately  by  extraction ;  but  in  order 
to  gain  room  for  the  extraction  of  the  child  it  may  be  necessary,  after 
having  loosened  the  uterus  from  the  vagina  and  the  bladder,  to  split 
the  uterine  wall  in  the  median  line  or  the  anterior  and  posterior  wall 
from  six  to  ten  inches  above  the  internal  os.  This  has  been  called 
vaginal  Cesarean  section.  After  the  removal  of  the  child  the  uterus 
itself  is  extirpated  through  the  vagina. 

If  the  pelvis  is  so  narrow  as  to  make  vaginal  manipulations  diffi- 
cult, the  total  abdominal  hysterectomy  is  indicated. 

The  immediate  result  of  hysterectomy  for  carcinoma  cervicis  is 
satisfactory  in  so  far  as  recovery  from  the  operation  is  concerned,  but 
it  is  quite  exceptional  that  the  patient  lives  more  than  three  years 
after  the  operation. 

The  same  method  has  been  used  in  the  sixth  and  seventh  months 
of  pregnancy,  the  anterior  wall  of  the  uterus  being  incised,  the  foetus 
extracted,  and  then  the  uterus  extirpated  from  the  vagina. 

The  vaginal  operation  has  the  advantage  of  avoiding  infection 
during  the  operation  and  an  abdominal  cicatrix  ;  but  if  the  child  is 
alive,  its  chances  are  much  better  if  it  is  delivered  by  abdominal 
Caesarean  section,  whatever  may  be  decided  as  to  the  best  way  of 
removing  the  uterus. 

Ovarian  Cyst. — Diagnosis. — Many  a  poor  girl  has  been  exposed  to 
the  suspicion  of  having  sacrificed  her  virtue  when  in  reality  she  was 
suffering  from  an  ovarian  cyst.  The  physician  should,  therefore,  use 
every  means  of  clearing  the  diagnosis.  As  a  rule,  menstruation  stops 
in  pregnancy  and  continues  in  the  person  who  has  an  ovarian  cyst. 
The  ovarian  tumor  grows  more  slowly  than  the  pregnant  uterus.  It 
may  be  felt  as  a  separate  mass  only  indirectly  connected  by  a  pedicle 
with  the  uterus,  while  in  pregnancy  tumor  and  cervix  are  so  inti- 
mately connected  that  they  move  together.  Pregnancy  is  character- 
ized by  numerous  signs,  especially  the  fetal  heart-sound  and  the  uter- 
ine souffle,  fetal  parts  may  be  felt,  fetal  movements  may  be  observed, 
ballottement  may  be  produced,  the  cervix  and  lower  uterine  segment 
are  softened,  the  vagina  has  a  purplish  color,  often  a  drop  of  fluid 
may  be  pressed  from  the  breasts, — all  of  which  signs  are  lacking  in 
connection  with  an  ovarian  cyst. 


296  ABNORMAL   PREGXAXCY. 

But  a  pregnant  uterus  and  an  ovarian  cyst  may  be  found  com- 
bined and  make  the  diagnosis  ver)^  difficult.  Tliis  complication  of 
pregnancy  is  not  very  rare,  and  may  influence  the  treatment  consider- 
ably. It  may  occur  even  ^vhen  both  ovaries  form  large  tumors,  and 
so  much  more  so  when  only  one  is  affected.  As  a  rule,  there  is  no 
menstruation.  Tlie  ovarian  tumor  may  be  known  to  have  existed 
before  pregnancy  began.  Otherwise  only  a  most  careful  abdominal 
and  vaginal  examination,  combined  with  due  reference  to  the  oft- 
named  symptoms,  can  clear  up  the  diagnosis.  When  the  presence 
of  one  child  is  made  out,  the  investigation  must  next  be  directed 
towards  the  second  mass,  with  a  view  to  ascertain  whether  the  case 
is  simply  one  of  t^^ins  or  of  uterogestation  combined  Avith  an  ovarian 
tumor. 

The  complication  mth  an  ovarian  cyst  may  give  rise  to  intolerable 
suffering,  on  account  of  the  distention  of  the  abdominal  wall  and 
compression  of  the  thoracic  organs.  The  growing  uterus  may  cause 
torsion  of  the  pedicle  of  the  ovarian  cyst,  an  extremely  dangerous 
condition. 

Treatment. — The  simultaneous  growth  of  the  pregnant  uterus  and 
an  ovarian  cyst  will,  in  most  cases,  be  a  source  of  so  much  discom- 
fort, or  even  be  attended  by  such  dangers,  that  interference  is  called 
for  during  pregnancy.  Three  methods  are  then  at  our  disposal : 
1,  artificial  abortion  or  induction  of  premature  labor;  2,  tapping  the 
cyst;  3,  ovariotomy.  The  writer  does  not  think  this  complication 
is  sufficient  to  indicate  artificial  abortion,  the  other  means  being  at 
our  disposal.  If  possible,  we  should  wait  until  the  child  is  viable, 
preferably  even  until  the  thirty-sixth  week  of  pregnancy,  and  then 
induce  labor.  Tapping  has  given  excellent  results  as  a  palliative 
measure,  to  be  followed  by  ovariotomy  after  the  puerperium  is  over ; 
and  there  is  no  serious  objection  to  it,  provided  it  is  performed 
by  a  man  prepared  to  do  ovariotomy  if  untoward  sequences  should 
develop.  Ovariotomy  has  been  performed  many  times  during  preg- 
nancy. The  dangers  of  the  operation  are  very  slightly  increased ;  but 
often  it  is  followed  by  miscarriage.  It  is,  therefore,  best  to  postpone 
it  until  after  the  puerperium,  and  during  pregnancy  be  satisfied  with 
induction  of  premature  labor  or  tapping  the  cyst,^  or  at  least  to  defer 
the  operation  until  the  child  is  fully  viable. 

Operations  during  Pregnancy. — In  general,  operations  should  as 
far  as  possible  be  avoided  during  pregnancy,  on  account  of  the  danger 
of  producmg  abortion.  It  seems  that  interference  with  the  rectum  is 
particularly  liable  to  have  this  effect.  As  to  the  genitals,  the  farther 
[he  seat  of  the  operation  is  removed  fi'om  the  uterus  the  less  is  the 

^  As  for  the  modus  operandi  see  Garrigues,   Diseases  of  Women,   third  ed., 

pp.  197,  640. 


DISEASES    OF    THE    GENITAL    ORGANS.  297 

danger  of  provoking  abortion.  Sometimes,  however,  operations  may 
be  imperatively  indicated  by  the  pregnancy  itself,  as  in  cases  of  ectopic 
gestation  ;  or  the  advantages  to  be  obtained  by  an  early  operation  may 
be  so  great  that  it  should  be  performed,  even  if  we  have  to  sacrifice 
the  child, — for  instance,  the  removal  of  an  ovarian  cyst  or  the  extir- 
pation of  the  cancerous  uterus.  I  also  allow  minor  operations  on  the 
teeth,  such  as  filling  of  carious  cavities  and  even  avulsion,  if  the 
affected  tooth  causes  much  distress. 

§  5.  Displacements. — Anteflexion. — Anteflexion  of  the  uterus 
opposes  a  much  more  serious  obstacle  to  impregnation  than  one 
would  expect,  w^hen  one  thinks  of  cases  of  pregnancy  occurring  under 
the  most  unfavorable  circumstances, — for  instance,  stenosis  of  the 
hymen  or  vagina,  leaving  only  a  hardly  visible  aperture  for  the  en- 
trance of  the  spermatozoids,  or  even  total  atresia,  and  communication 
between  the  uterus  and  the  rectum,  through  Avhich  latter  organ  copu- 
lation took  place.  Still,  there  cannot  be  any  doubt  about  the  correct- 
ness of  the  statement  that  anteflexion  is  a  barrier  to  conception,  since 
we  are  so  often  consulted  by  women  with  this  deformity  who  are 
in  perfect  health,  but  sterile,  and  the  excellent  effect  of  operations 
by  which  an  easier  access  to  the  uterine  cavity  is  opened  for  the 
spermatozoids. 

Again,  if  a  woman  suffering  from  anteflexion  conceives,  there  is 
danger  of  miscarriage  or  severe  vomiting  during  pregnancy,  which  may 
interfere  so  much  with  the  general  nutrition  that  it  becomes  necessary 
to  induce  abortion  artificially. 

On  the  other  hand,  pregnancy,  if  it  goes  on  to  term,  is  the  radical 
cure  for  anteflexion. 

There  is  not  much  to  be  done  for  anteflexion  during  pregnancy, 
except  to  recommend  the  dorsal  posture  and  after  the  end  of  the  third 
month,  when  the  fundus  of  the  uterus  reaches  the  abdominal  wall,  the 
use  of  an  abdominal  supporter.  Excessive  vomiting  will  be  considered 
later. 

Anteversion  is  hardly  of  any  interest  to  the  obstetrician.  It  offers 
little  obstacle  to  conception  and  hardly  any  to  the  rising  of  the  impreg- 
nated womb,  except  when  this  has  been  artificially  fastened  to  the 
vagina  in  operations  for  retroflexion,  in  which  case  it  may  give  rise  to  a 
most  formidable  complication  of  labor,  which  will  be  considered  later.^ 

Retroflexion  of  the  Uterus. — In  retroflexion  the  genital  canal 
seems  to  have  a  direction  more  favorable  to  conception  than  in  ante- 
flexion. While  patients  afflicted  with  the  latter  quite  commonly  are 
sterile,  those  in  whom  the  uterus  is  bent  the  other  way  often  have 
large  families.     As  a  rule,  the  uterus  rises  gradually  out  of  the  pelvic 

^  Antedisplacemeuts  are  described  in  Garrigues,   Diseases  of  Women,  third 
ed.,  pp.  453-465. 


298 


ABNORMAL  PREGNANCY. 


cavit}^  and  the  retroflexion  changes  into  the  physiological  anteflexion  ; 
but  sometimes  the  retroflexecl  uterus  becomes  impacted,  and  then  we 
have  to  deal  with  a  very  dangerous  condition  (Fig.  259). 

The  first  symptom  that  brings  the  patient  to  seek  the  advice  of  the 
doctor  is,  as  a  rule,  retention  of  urine.  Constipation  is  also  present 
and  some  pelvic  pain.  On  vaginal  examination  the  retroflexed  en- 
larged uterus  is  felt  pressing  on  the  rectum.  In  neglected  cases  the 
whole  mucous  membrane  of  the  bladder  has  been  thrown  off  in  one 
piece  by  a  diphtheritic  process  in  the  submucous  connective  tissue. 
The  pregnancy  may  terminate  in  spontaneous  abortion  or  the  bladder 

Fig.  259. 
C 


sip 


Impaction  of  retroflexed  gravid  uterus.    (Schatz.)    £  U,  retroflexed  uterus ;  R,  rectum ;  B.  bladder ; 
C,  cer\-ix  uteri ;  V,  vagina  ;  U,  urethra ;  S  P,  sj'mphysis  pubis. 

may  rupture  and  the  patient  die  from  peritonitis,  uraemia,  gangrene  of 
the  bladder,  or  septiceemia. 

In  rare  cases  a  part  of  the  posterior  wall  of  the  uterus  remains  in 
the  pelvis,  a  condition  called  partial  retroflexion  of  the  gravid  iderus. 
Then  the  uterus  and  the  fostus  are  felt  partially  above  the  symphysis 
and  partially  in  the  vagina.  This  condition,  as  a  rule,  does  not  offer 
any  difficulty,  but  may  exceptionally  end  in  abortion  or  premature 
labor  between  the  sixth  and  the  eighth  months. 

Treatment.— Yiv?,i  the  bladder  should  be  emptied  with  the  catheter. 
Next,  the  faulty  position  of  the  uterus  should  be  corrected  as  soon  as 
possible.  In  most  cases  this  can  be  done  by  placing  the  woman  in 
Sims's  position  and  introducing  the  index  and  middle  finger  with  the 
volar  surface  turned  back  towards  the  physician.     The  replacement 


DISEASES   OF   THE   GENITAL   ORGANS. 


299 


should  be  tried  in  the  corners  of  the  pelvis,  in  front  of  the  iliosacral 
joint,  where  there  is  most  space.  If  it  does  not  succeed,  the  patient 
should  be  placed  in  the  knee-chest  position  (Fig.  260)  and  a   cotton 


Fig.  260. 


Genupeetoral  position.     (H.  F.  Campbell.) 


tampon  held  in  forceps  should  be  substituted  for  the  fingers.  When 
the  uterus  has  been  replaced,  it  should  be  kept  in  its  new  position 
and  prevented  from  falling  back  again  by  means  of  a  large  Hodge- 
Emmet  or  Albert  Smith  pessary  (Fig.  261),  which  should  be  worn 
till  the  end  of  the  fourth  month,  when  the  uterus  has  acquired  such 
dimensions  that  it  can  no  longer  become  retroflexed. 

If  the  uterus  is  not  easily  replaced,  the  patient  should  be  anaesthet- 
ized. If  manual  reposition  through  the  vagina  does  not  succeed,  the 
hand  may  be  passed  through  the  rectum,  which  sometimes  is  more 
effective,  and  replacement  may  be  seconded  by  pulling  the  cervix 
down  from  the  vagina  with  the  fingers  or  bullet-forceps. 

Another  principle,  that  of  steady  elastic  pressure,  has  been  suc- 
cessfully applied  to  the  reposition 
of  the  retroflexed  uterus.  It  may 
be  exercised  by  means  of  Brauiri's 
colpeurynter  or  any  other  rubber 
bag  such  as  the  one  delineated  in 
Fig.  417.  After  having  been  disin- 
fected it  is  introduced  into  the  va- 
gina against  the  fundus  uteri  and 
filled  with  as  much  sterilized  water 
or  lysol  emulsion  as  the  patient  can 
bear.  If  the  patient  cannot  urinate,  the  urine  is  drawn  with  catheter 
or  the  bag  is  momentarily  emptied.  The  same  principle  is  employed 
more  effectively  in  Aveling\s  repositor.  This  consists  of  a  little  hard- 
rubber  cup  which  presses  against  the  fundus,  and  an  S-shaped  rod 
which  protrudes  from  the  vulva  and  carries  pressure  made  at  the 


Fig.  261. 


IIoditre-Kmmet  pessary. 


300  ABNORMAL    PREGNANCY. 

lower  end  up  in  the  direction  of  the  pelvic  axis.  To  this  lower  end 
are  attached  four  elastic  cords  which  are  drawn  through  rings  fastened 
to  a  binder  surrounding  the  abdomen.  Two  of  the  cords  are  brought 
forward  and  two  backward,  enabling  us  to  press  in  the  right  direction. 
This  apparatus  has  the  advantage  over  the  colpeurynter  that  the 
distention  of  the  vagina,  which  is  not  only  painful  but  also  might  cause 
abortion,  is  avoided. 

If  all  attempts  at  reposition  are  fruitless,  the  uterus  should  be 
punctured  from  the  vagina  and  the  liquor  amnii  aspirated,  whicli,  as  a 
rule,  gives  immediate  relief  from  pressure,  but  is  soon  followed  by 
abortion. 

Retroversion  of  the  uterus  is  comparatively  rare,  and  if  a  retro- 
verted  uterus  becomes  impregnated  it  gradually  changes  into  retro- 
flexion or  retroflexion  combined  with  retroversion.^ 

Prolapse  and  Procidentia  of  the  Uterus.^ — No  case  of  pregnancy 
in  a  completely  prolapsed  uterus  at  term  is  known,  but  the  condition 
has  been  observed  and  described  at  an  earlier  stage.  On  the  other 
hand,  pregnancy  in  a  partially  prolapsed  uterus  which  still  remains 
in  the  vagina  and  the  pelvis  is  not  very  rare.  Sometimes  the  pro- 
lapse is  more  apparent  than  real,  a  considerable  hypertrophy  of  the 
cervix,  especially  the  supravaginal  portion,^  making  the  cervix  appear 
outside  of  the  vulva,  while  the  body  of  the  uterus  is  in  or  above 
the  pelvis. 

When  the  uterus  grows,  as  a  rule,  it  is  drawn  up  until  it  is  so  large 
that  it  cannot  re-enter  the  pelvic  brim,  so  that  women  with  this  afflic- 
tion are  comparatively  free  from  it  during  their  pregnancy,  and  preg- 
nancy and  labor  pass  off  without  disturbance. 

In  the  earlier  months  of  pregnancy  the  uterus  may  by  some  acci- 
dent be  suddenly  propelled  outside  the  body.  Then  it  becomes 
oedematous,  blood  is  extravasated  around  or  in  the  ovum,  and  the 
woman  aborts. 

Treatment. — The  prolapsed  uterus  should  be  brought  back  to  its 
place,  and  in  so  doing  we  should  take  particular  care  to  bring  the 
fundus  forward,  as  otherwise  it  is  very  apt  to  go  backward  and  consti- 
tute a  retroflexion.  This  reposition  is,  as  a  rule,  easy  enough,  but  not 
so  the  retention.  The  vagina  being  enormously  dilated  and  softened, 
and  all  tissues  that  normally  hold  the  uterus  in  place  being  relaxed, 
the  uterus  sinks  down  again.  Common  pessaries  find  no  support. 
Sometimes  a  large  thick  rubber  ring  (Mayer's  pessary)  may  be  able  to 
retain  the  uterus  in  place,  or  a  cup  and  stem  pessary  attached  to  an 
abdominal  supporter  may  be  able  to  do  so.     If  not,  the  patient  must 

'^  Information  about  the  retrodisplacements  is  found  in  Garrigues,  Diseases 
of  Women,  third  ed.,  p.  464  and  following. 

Mbid.,  p.  478.  '  Ibid.,  p.  446. 


DISEASES    OF   THE    GENITAL    ORGANS.  301 

be  kept  in  a  recumbent  position  until  the  uterus  becomes  so  large  that 
it  can  no  longer  fall  down. 

When  the  cervix  is  so  much  hypertrophied  that  it  may  be  expected 
to  oppose  a  serious  obstacle  to  the  passage  of  the  child,  it  may  be 
amputated  during  pregnancy. 

CEdema  of  the  Cervix. — During  pregnancy,  labor,  and  even  after 
delivery,  the  cervix  may  become  (^edematous  and  form  a  large  soft 
swelling.  It  is  rather  towards  the  end  of  pregnancy  than  in  the  first 
months  that  this  condition  has  been  observed.  The  patients  complain 
that  something  is  coming  out  of  their  genitals  during  straining  or  in 
walking,  which  again  disappears  during  rest.  Besides  they  may  be 
constipated  or  find  difficulty  in  urinating. 

At  the  vulva,  partially  protruding  from  it,  is  found  a  tumor  of  red 
or  bluish  color,  soft,  reducible  on  pressure,  which  proves  to  be  the 
swollen  cervix.  The  finger  may  be  introduced  through  the  cervical 
canal,  which  is  found  much  elongated  and  measuring  from  three  to 
four  inches. 

The  cause  of  this  oedema  is  not  always  clear,  but  sometimes  pressure 
exercised  by  a  tumor  in  the  pelvis  on  the  lower  uterine  segment 
accounts  for  it.  The  disappearance  of  the  swelling  during  the  recum- 
bent position  distinguishes  it  from  hypertrophy,  and  the  normal  situa- 
tion of  the  fundus  from  prolapse. 

The  condition  is  of  importance  since  it  is  apt  to  lead  to  premature 
labor. 

Treatment. — The  swelling  should  be  reduced  by  pressure  in  the 
recumbent  position,  and  then  a  couple  of  tampons  should  be  placed  in 
the  vagina  and  kept  in  place  with  a  T  bandage.  The  patient  should 
be  kept  in  a  recumbent  position,  and  if  she  is  constipated  her  bowels 
should  be  moved. 

Partial  (Edema. — Sometimes  the  oedema  affects  only  a  part  of  the 
cervix,  especially  the  anterior  lip.  Thus  a  tumor  may  be  formed  that 
interferes  with  the  birth  of  the  child. 

Hernia  Uteri,  or  Hysterocele. — In  exceedingly  rare  cases  the 
uterus  is  found  forming  the  contents  of  a  hernia,  femoral,  inguinal,  or 
umbihcal. 

The  foetus  may  be  carried  to  term  in  this  abnormal  situation  ;  but 
if  the  case  comes  under  observation  during  pregnancy  before  the  child 
is  viable,  the  uterus  should  be  cut  down  upon  and  removed  by  abdo- 
minal hysterectomy.^ 

At  the  end  of  pregnancy,  the  uterus  should  be  incised  and  the 
child  taken  out  as  in  Caesarean  section  performed  when  the  uterus  is 
in  the  abdominal  cavity.  As  to  the  uterus,  it  may  either  be  left  till 
after  involution   has   diminished   its   volume   and   blood    supply    or 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  517. 


302  ABNORMAL   PREGXAXCY. 

replaced  into  the  abdominal  cavity  or  extirpated  at  the  level  of  the 
cervix, — Porro's  operation,  ^vhich  will  be  described  later. 

The  pregnant  uterus  may  be  found  in  a  ventral  hernia,  which  may 
have  existed  before  impregnation  took  place  or  which  may  have  been 
formed  during  pregnancy  by  the  distention  of  the  gromng  uterus. 
These  cases  are  not  rare  in  women  upon  whom  laparotomy  has  been 
performed.^  Either  the  edges  of  the  wound  were  not  properly  brought 
together,  or  suppuration  set  in,  or  the  cicatrix  formed  at  the  time 
became  wider  and  thinner  by  subsequent  intra-abdominal  pressure. 
In  these  cases  the  recti  muscles  separate  in  the  median  line,  and  form 
concave  edges  when  the  woman  lies  on  her  back  and  tries  to  raise 
her  chest.  In  the  gap  we  feel  under  the  thinned  skin  the  abdomi- 
nal contents — intestines,  uterus,  ovaries  and  tubes — with  unusual 
distinctness. 

For  these  patients  there  is  nothing  to  be  done  except  to  let  them 
wear  a  well-fitting  abdominal  supporter.  After  their  puerpery  the 
gap  in  the  abdominal  wall  may  be  closed  by  a  secondary  operation, 
in  which  case  union  of  the  aponeurosis  by  the  cobblers  stitch  is  partic- 
ularly recommendable.^ 

Ectopic  Gestation. — As  we  have  seen  above,  the  fertilized  ovum 
is  destined  to  be  embedded  in  the  mucous  membrane  of  the  uterine 
cavity,  but,  unfortunately,  by  one  of  the  saddest  errors  of  nature,  it 
may  also  develop  in  the  ovary  or  the  tubes.  This  condition  used  to 
be  known  as  extra-uterine  pregnancy;  but  since  the  development 
may  take  place  in  that  part  of  the  tube  that  traverses  the  uterine 
wall,  the  modern  name  ectopic  gestation  is  preferable.  It  is  by  no 
means  a  rare  condition,  as  appears  by  a  research  of  medical  journals 
during  the  last  thirty  years  and  the  material  that  comes  under  ob- 
servation in  hospitals,  lying-in  institutions,  and  the  private  practice 
of  gyneecologists. 

Ectopic  gestation  may  be  divided,  according  to  the  place  in  which 
the  foetus  develops,  into  ovarian^  tubal,  tuba-ovarian,  tiibo-uterine,  or 
interstitial,  uterotubal,  and  secondary  abdominal  pregnancy,  of  which 
the  tubal  is  the  most  common. 

Ovarian  pregnancy  is  a  rare  form,  in  which  fertilization  takes  place 
in  the  ovum  while  it  is  yet  retained  in  the  interior  of  the  Graafian 
follicle.  But  how  do  the  spermatozoids  get  there,  and  why  does  the 
ovum  stay  there  ?  We  can  imagine  two  roads  the  spermatozoids  may 
take, — either  through  the  corresponding  tube,  and  that  is  doubtless  the 
common  way,  or,  if  that  is  impervious,  through  the  tube  of  the  oppo- 
site side,  by  so-called  external  migration  of  the  semen.     The  ovary  is 

1  Garrigues,  Diseases  of  Women,  third  ed.,  p.  643. 

=>  Garrigues,  ibid.,  p.  649  ;  "Secondary  Operations,"  Trans.  Amer.  Gyn.  See, 
1897,  vol.  xxii.  ;  Annals  of  Gynaecology  and  Pediatrics,  Boston,  1897. 


DISEASES    OF   THE   GENITAL   ORGANS. 


303 


often  the  seat  of  chronic  inflammation,  which  has  resulted  in  adhesive 
masses  surrounding  the  ovary  like  a  rind.  The  ripe  follicle  may  never- 
theless open  on  its  surface,  admitting  the  spermatozoids,  but  the  adhe- 
sions may  offer  an  obstacle  to  the  escape  of  the  ovum.  The  opening 
in  the  follicle  may  remain  open  after  the  ovum  has  been  fecundated, 
and  then  the  fetal  sac  may  develop  without  hinderance  in  the  abdomi- 
nal cavity  ;  or  it  may  close,  when  the  whole  fetal  sac  will  be  developed 
within  the  narrow  space  of  the  ovary  itself,  whose  distensibility  is 
limited,  and  which  will  at  an  early  date  rupture  under  the  pressure 
from  within. 

The  anatomical  proof  that  an  ectopic  gestation  has  its  seat  in  the 
ovary  consists  in  the  presence  of  both  tubes,  the  absence  of  one  ovary, 
the  ovarian  ligament  ending  in  the  fetal  sac ;  and  sometimes  even  fol- 

FiG.  262. 


Interstitial,  or  tubo-uterine,  pregnancy.  (Mayer.)  rupL,  place  of  rupture  in  the  wall  of  the 
left  horn  of  the  uterus,  with  protruding  villi  of  the  chorion  ;  lig  rot  d,  right  round  ligament ;  lir/.rot  s., 
left  round  ligament ;  OS  M^.,  OS  uteri. 


licles  and  ova  have  been  found  in  the  fetal  sac,  elements  which  are 
purely  ovarian  in  character. 

The  tuho-ovarian  variety  is  still  rarer  than  the  purely  ovarian,  being 
possible  only  when  the  tube  was  adherent  to  the  ovary  before  impreg- 
nation and  a  follicle  bursts  in  such  a  place  that  the  spermatozoids  can 
reach  its  interior.  In  this  variety  the  fetal  sac  is  formed  partially  of 
the  ovary  and  partially  of  the  fimbriated  end  of  the  tube. 

The  interditial  or  tubo-uterine  pregnancy  (Fig.  262)  is  also  very  rare. 
It  develops  in  the  innermost  part  of  the  tube,  which  lies  in  the  wall  of 
the  horn  of  the  uterus.  This  is  not  extra-uterine,  since  the  develop- 
ment takes  place  in  the  wall  of  the  uterus  ;  but  it  is  ectopic,  because 
the  sac  is  not  developed  in  the  cavity  of  the  uterus,  its  normal  place. 

This  form  may  be  very  like  a  case  of  pregnancy  in  the  rudimentary 


304 


ABNORMAL    PREGXAXCY. 


horn  of  a  uterus  unicornis  ;  but  the  distinctive  feature  is  that  only  one 
side  of  the  uterus  develops  and  the  fundus  thereby  becomes  almost 
perpendicular  (Fig.  263),  while  in  the  rudimentary  horn  of  a  unicorn 
uterus  just  the  opposite  is  the  case :  the  fundus  is  transverse  and 
wide  and  the  appendages  start  from  the  top  of  the  well-developed 
horn  (Fig.  264). 

Both  these  varieties  of  pregnancy  differ  from  a  tubal  pregnancy  by 
being  situated  inside  of  the  round  ligament,  whereas  in  tubal  preg- 

FiG.  263. 


Interstitial  pregnancy.     (Ruge.) 

nancy  the  tumor  is  developed  outside  of  the  point  of  insertion  of  this 
ligament. 

When  the  interstitial  sac  grows,  it  may  extend  into  the  uterine 
cavity,  and  thus  approach  the  condition  of  a  normal  pregnancy  ;  or,  on 
the  other  hand,  it  may  enter  the  free  part  of  the  tube,  forming  the 
variety  known  as  uterotubal  pregnancy,  which  practically  is  the  same 
as  the  purely  tubal  pregnancy,  except  in  so  far  that  the  uterine  wall  is 
imphcated. 

Far  more  common  than  any  of  the  varieties  so  far  described  is  the 
true  tubal lyregnancij  (Fig.  265),  where  the  ovum  is  embedded  on  the 
mucous  membrane  of  the  tube  itself— the  isthmus,  ampulla,  or  fim- 
brige, — and  most  commonly,  again,  not,  as   one  might  be  inclined  to 


DISEASES    OF   THE    GENITAL    ORGANS. 


305 


expect,  a  priori^  in  the  narrow  isthmus,  but  in  the  comparatively  wide 
ampulla.  As  to  the  fimbriated  end,  either  the  whole  may  form  a  flat 
cup  on  which  the  ovum  is  implanted  like  an  acorn  in  its  involucre, 
or  the  ovum  may  have  been  embedded  on  the  long  fimbria  ovarica 
that  extends  from  the  ovary  to  the  tube. 

Etiology. — For  tubal  pregnancy  to  occur,  it  nmst  be  possible  for 
the  spermatozoids  to  pass,  and,  on  the  other  hand,  there  must  be  an 
obstruction  which  retains  the  fertilized  ovum  on  its  way  to  the  uterine 
cavity.  In  this  respect  we  remember  that  the  spermatozoid  in  its  full 
length  is  five  times  smaller  than  the  diameter  of  an  ovum,  and  conse- 

FiG.  264. 


uterus  unicornis  with  pregnancy  in  the  rudimentary  horn.     (Ruge.) 


quently  it  may  pass  through  a  many  times  smaller  opening.  Further- 
more, the  spermatozoid  possesses  a  very  lively  movement  of  its  own, 
which  pushes  it  in  the  direction  of  the  inner  genitals,  whereas  the  ovum 
is  inert  and  must  depend  for  its  transportation  on  the  movement  of  the 
cilia  of  the  cells  lining  the  tubes.  A  mere  retardation  in  this  move- 
ment may  therefore  perhaps  suffice  to  cause  the  ovum  to  become 
embedded  on  the  mucous  membrane  of  the  tube,  and,  of  course,  still 
more  so  a  loss  of  cilia  or  of  part  of  the  epithelium.  Now,  pathological 
anatomy  teaches  that  in  cases  of  ectopic  gestation  we  sometimes  find 
the  tube  taking  an  unusually  winding  course,  and  that  quite  frequently 

20 


306 


ABNORMAL    PREGNANCY. 


there  is  a  catarrh  of  the  tube,  or  even  a  pyosalpinx  ;  and  stih  more 
frequently  the  tube  is  covered  with  peritonitic  adhesions,  which  distort 
its  course  or  form  kinks  and  constricting  bands,  ah  of  which  w^ould 
tend  to  place  obstacles  in  the  way  of  the  normal  migration  of  the  ovum 
from  the  ovary  to  the  uterus.  It  has  also  been  noticed  that  multiple 
fetation  is  found  with  comparative  frequency  in  ectopic  gestation,  which 
makes  one  think  that  perhaps  two  or  three  ova  try  to  pass  the  tube  at 
the  same  time  and  become  impacted  in  its  narrow  canal  and  among 
its  deep  folds. 

It  has  also  been  noticed  that  ectopic  gestation  is  much  more  com- 
mon among  women  who  have  borne  children  than  among  primiparse, 


Fig.  265. 


Tubal  prcp:ii;incy,  ruptured  at  the  end  of  the  third  month  of  gestation.  (Wood's  Museum,  Belle- 
vue  Hospital,  No.  1219.)  a,  uterus  seen  from  behind,  containing  several  myomas;  6,  right  ovary; 
c,  ruptured  tube ;  d,  left  ovary ;  e,  foetus. 


the  cause  of  which  is  undoubtedly  to  be  found  in  the  healthy  condi- 
tion of  the  genital  canal  of  these  latter,  while  in  the  former  childbirth 
itself  and  other  nosogenic  influences  may  have  become  the  source  of 
tubal  catarrh,  pyosalpinx,  and  perimetric  inflammation.  We  find  par- 
ticularly ectopic  gestation  in  cases  of  secondary  sterility, — that  is  to  say, 
a  woman  gives  birth  to  a  child,  then  she  does  not  conceive,  or  at  least 
no  pregnancy  develops  for  several  years,  and  when  she,  finally,  con- 
ceives again  the  ovum  is  arrested  before  reaching  the  uterine  cavity. 
Tubal  pregnancy  is  much  more  common  on  the  left  side  than  on  the 
right,  which  probably  is  due  to  pressure  from  the  rectum  and  the 


DISEASES   OF    THE    GENITAL    ORGANS. 


307 


absence  of  a  valve  in  the  left  ovarian  vein,  and  its  debouchure  in  the 
renal  vein  at  a  right  angle. 

Development. — The  mucous  membrane  of  the  tube  swells  and 
forms  a  decidua,  the  epithelial  cells  are  lost,  while  a  proliferation  of 
connective-tissue  cells  takes  place  and  the  large  decidual  cells  are 
formed.  The  muscular  coat  of  the  tube  undergoes  also  a  develop- 
ment, but  it  cannot  keep  pace  with  the  growth  of  the  fetal  sac,  the 
muscular  bundles  become  separated  from  one  another,  and  the  whole 
wall  becomes  so  thin  that,  unable  to  withstand  the  expansion  any- 
longer,  it  ruptures.  Most  frequently  the  rupture  supervenes  in  the 
third  or  fourth  month  of  gestation,  rarely  in  the  first  or  second,  and 
still  more  infrequently  after  the  fourth.     If  this  rupture  takes  place 

Fig.  266. 


—fu&rus: 


Intraligamentous  tubal  pregnancy.    (Schauta.)     Qrav.  tub.,  tubal  gravidity  ;  lig.  rot.,  round 
ligament;  or.  ext.,  orificium  externum. 


downward,  the  blood  may  enter  between  the  two  layers  of  the  broad 
ligament  and  lift  the  peritoneum  from  the  abdominal  wall,  but  finding 
considerable  resistance  in  this  closed  cavity,  it  ceases  to  flow,  coagu- 
lates, and  forms  a  hcematoma.  The  foetus  may  continue  to  develop  in 
this  locality,  constituting  a  large  intraligamentous  tumor  (Fig.  266).  If, 
on  the  other  hand,  the  rupture  takes  place  upward  and  the  tear  goes 
through  the  placenta,  the  blood  may  inundate  the  peritoneal  cavity  and 
the  patient  may  bleed  to  death  in  a  very  short  time  by  intrapejntoneal 
hemorrhage.  But  the  rupture  may  take  place  before  the  placenta  is 
developed  or  it  may  not  implicate  this  organ.  The  quantity  of  blood 
lost  maybe  small ;  it  may  flow  slowly  and  even  with  intervals.  There 
may  be  old  adhesions  in  the  neighborhood  of  the  rift.  Under  these 
favorable  circumstances  the  blood  may  become  encysted,  the  intes- 
tines, the  omentum,  the  uterus,  and  the  wall  of  the  pelvis  becoming 


308  ABNORMAL   PREGNANCY. 

agglutinated  and  forming  a  roof  over  theextravasated  blood,  a  con- 
dition which  is  called  hcematocele}  Finally  the  blood  may  coagulate 
and  by  peristaltic  movement  be  smeared  all  over  the  intestines  and 
the  walls  of  the  peritoneal  cavity,  where  it  is  gradually  absorbed  by 
the  lymphatics. 

Wherever  the  ovum  is  embedded,  the  uterus  participates  in  the 
development.  Although  empty,  it  increases  in  size  by  the  usual 
muscular  hyperplasia  and  hypertrophy,  and  a  decidua  forms.  Later, 
but,  as  a  rule,  within  the  first  three  months,  this  irritates  the  uterus 
as  a  foreign  body,  contractions  are  elicited,  and  the  decidua  is  thrown 
off  in  shreds  or  as  a  continuous  cast  of  the  uterine  cavity,  which 
process  is  accompanied  by  more  or  less  uterine  hemorrhage. 

The  tubal  decidua  vera  is  less  perfect  than  that  normally  formed 
in  the  uterus.  A  reflexa  forms  also,  but  does  not  cover  the  whole 
ovum.  A  placenta  is  developed,  the  maternal  blood  being  furnished 
by  the  enlarged  tubal  blood-vessels. 

Another  way  in  which  the  tube  rids  itself  of  the  foetus  is  by  pushing 
it  to  one  of  its  ends.  By  peristaltic  movements  the  ovum  may  be 
thrust  into  the  cavity  of  the  uterus,  whence  it  may  immediately  be 
expelled  through  the  os,  or  it  may  be  retained  for  months  in  the  uterine 
cavity  until  it  is  expelled  by  abortion,  or  it  may  even  be  carried  and 
continue  growing  till  a  time  when  the  child  may  be  born  alive  by  a 
normal  labor.^  But  all  this  is  likely  to  happen  only  in  cases  of  tubo- 
uterine  pregnancy  or  at  least  in  cases  of  tubal  pregnancy  where  the 
ovum  is  embedded  in  the  inner  part  of  the  tube.  If  it  is  implanted 
near  the  fimbriated  end,  it  is  more  liable  to  be  pushed  through  the 
abdominal  opening  of  the  tube  and  fall  into  the  abdominal  cavity,  a 
process  which  aptly  has  been  dubbed  tubal  abortion.  It  occurs,  as  a 
rule,  within  the  first  three  months  of  pregnancy.  It  may  take  place 
suddenly,  and  complete  tubal  abortion  is  then  apt  to  be  accompanied 
by  severe,  even  fatal,  cataclysmic,  intraperitoneal  hemorrhage ;  or  the 
ovum  may  gradually  be  loosened  and  pressed  into  the  abdominal 
cavity — so-called  protracted  tubal  abortion.  Then  the  condition  is 
much  like  that  described  above  as  being  found  in  certain  cases  of 
rupture  of  slow  formation.  The  hemorrhage  is  moderate,  the  blood 
finds  time  to  coagulate,  protective  adhesions  encyst  it,  and  the  result 
is  a  haematocele.  Tubal  abortion  is  commonly  accompanied  by  uterine 
hemorrhage. 

In  cases  of  rupture  the  whole  fetal  sac  may  burst  and  the  naked 
foetus  fall  into  the  abdominal  cavity.  If  it  is  small,  it  may  be  entirely 
absorbed,  as  shown  experimentally  by  placing  young  foetuses  of  rabbits 

1  See  Garrigues,  Diseases  of  Women,  third  ed..  p.  686. 

^  Garrigues,  "Extra-uterine  Pregnancy  changed  into  Intra-uterine,"  Medical 
News,  December  12,  1885. 


DISEASES   OF   THE    GENITAL   ORGANS.  309 

into  the  peritoneal  cavity,  and  proved  by  the  frequent  absence  of  a 
foetus  Mobile  parts  of  the  placenta  are  found.  The  foetus  becomes 
invaded  by  colorless  blood-corpuscles  and  disappears  without  leaving 
a  trace.  Larger  foetuses  may  be  preserved  for  many  years,  so  that  the 
organs  and  even  the  microscopical  structure  remain  unchanged.  Or 
by  incrustation  v^ith  lime  salts  the  foetus  may  be  changed  into  a  stony 
mass — a  lithopcedion.  This  incrustation  may  take  place  in  the  skin 
and  other  soft  tissues  of  the  foetus  itself  or  in  the  surrounding  fetal 
sac  or  in  both  together.  Such  a  lithopaedion  has  been  carried  for 
half  a  century  in  the  abdomen.  Sometimes  the  soft  parts  of  the  foetus 
undergo  lipoid  degeneration, — that  is,  they  are  changed  into  a  fatty 
mass  like  that  adipocere  that  often  is  found  in  bodies  that  have  long 
been  buried. 

More  commonly,  however,  the  foetus  and  ovum  undergo  suppura- 
tion or  putrefaction  and  disintegration  ;  fistulous  tracts  form  through 
the  abdominal  wall,  into  the  intestine,  the  vagina,  or  the  bladder,  by 
which  ways  the  bones  of  the  skeleton  may  be  expelled ;  and  finally 
recovery  may  take  place  if  in  the  mean  time  the  patient  does  not  suc- 
cumb to  peritonitis  or  sepsis. 

At  the  time  of  rupture  the  foetus  may  also  remain  in  the  intact 
amnion  and  the  ovum  retain  its  connection  with  its  original  point  of 
embedding  in  the  ovary  or  the  tube.  Then  it  may  continue  to  grow 
until  the  normal  term, — secondary  abdominal  pregnancy.  At  term 
labor-pains  set  in,  the  foetus  dies,  chiefly  from  hemorrhage  at  the 
placental  site,  and  may  undergo  any  of  the  changes  just  mentioned, — 
suppuration,  putrefaction,  mummification,  or  petrifaction. 

As  to  the  blood  poured  into  the  abdominal  cavity  or  into  the  con- 
nective tissue  of  the  pelvis  and  the  abdominal  wall,  it  may  be  absorbed, 
or  it  may  form  an  abscess,  or  in  rare  cases  the  cyst  in  which  it  is  con- 
tained may  secondarily  rupture  into  the  peritoneal  cavity. 

In  exceptional  cases  the  foetus  may  remain  in  the  tube,  neither 
rupture  nor  tubal  abortion  occurring.  It  may  be  carried  till  the  end 
of  normal  pregnancy  ;  the  liquor  amnii  is  then  evacuated  through  the 
uterus,  and  the  fetal  sac  and  foetus  undergo  one  of  the  above-described 
changes.  The  germs  causing  suppuration  or  putrefaction  may  find 
their  way  in  through  the  uterus  or  be  derived  from  a  pyosalpinx  or 
by  invasion  from  the  intestinal  tract.  Much  more  commonly,  however, 
the  foetus  dies  at  an  earher  period  and  may  remain  in  the  tube ;  the 
liquor  amnii  is  absorbed,  the  foetus,  membranes,  and  extra vasated  blood 
form  together  an  oblong  mass  called  a  fleshy  mole.  Occasionally  it 
has  also  been  found  changed  into  a  hydatid  mole,  which  will  be 
described  later.  Or  the  foetus  may,  even  after  its  death,  act  as  a  source 
of  irritation,  cause  hemorrhage  in  its  surroundings,  and  finally  lead  to 
rupture  of  the  tube. 


310  ABNORMAL    PREGNANCY. 

While  the  foetus  remains  hvingin  the  tube,  it  is  exposed  to  abnormal 
pressure  in  its  close  quarters,  which  may  explain  v^hy  malformations 
are  comparatively  common  in  ectopic  gestation. 

Tubal  pregnancy  may  be  bilateral  or  there  may  be  found  two 
foetuses  in  the  same  tube. 

Symptoms. — Ectopic  gestation  may  take  its  course  to  full  term  with- 
out any  symptoms  calling  the  patient's  attention  to  her  dangerous  con- 
dition, until  finahy  labor  pains  set  in  and  no  child  appears.  But  much 
more  commonly  some  kind  of  unusual  accident  brings  her  to  seek 
medical  advice,  especially  attacks  of  severe  pain  in  the  lower  part  of 
the  abdomen,  a  pain  that  may  be  so  violent  that  if  standing  up  she 
sinks  right  down  on  the  spot,  unable  to  take  a  single  step.  At  other 
times  it  is  loss  of  blood  from  the  vagina  that  brings  her  to  the  physi- 
cian. Often  the  patient  complains  of  dysuria,  dyschezia,  or  dyspepsia, 
or  a  watery  fluid  is  discharged.  If  this  can  be  examined,  the  char- 
acteristic microscopic  appearance  of  liquor  amnii  will  at  once  settle  the 
diagnosis  of  pregnancy.  Otherwise  it  may  have  been  hydrorrhoea.  If 
shreds  of  the  decidua  or  the  whole  of  this  membrane  has  been  thrown 
off,  the  presence  of  decidua  cells  likewise  makes  the  diagnosis  of  preg- 
nancy certain.  Sometimes  we  find  the  symptoms  of  local  peritonitis, 
— fever  and  swelling. 

If  called  to  see  the  patient  when  rupture  or  tubal  abortion  has 
taken  place,  we  may  find  her  in  collapse,  with  a  sensation  of  a  warm 
fluid  entering  her  abdominal  cavity ;  faintness,  nausea,  vomiting ;  a 
frequent  small  or  imperceptible  pulse ;  a  subnormal  temperature ; 
dyspnoea ;  pallor ;  cold  clammy  extremities.  Often  blood  is  flowing 
from  the  vagina.  The  abdomen  is  distended  and  very  sensitive.  Con- 
sciousness is  preserved,  and  the  patient  feels  that  her  life  is  ebbing 
away. 

Diagnosis. — In  trying  to  diagnosticate  the  case,  we  should  first  find 
out  if  the  patient  is  pregnant,  by  passing  in  review  all  signs  of  this 
state.  If  a  regularly  menstruating  woman  skips  one  or  more  periods, 
the  probability  is  that  she  is  pregnant.  If  she  has  borne  a  child  before 
and  then  been  sterile  for  years,  the  suspicion  of  ectopic  gestation 
should  be  awakened. 

We  may  feel  the  uterus  soft  and  enlarged,  but  not  so  much  as  we 
would  expect  from  the  time  elapsed  since  the  last  menstruation. 
Attacks  of  pain  and  irregular  discharge  of  blood  make  it  more  likely 
that  we  have  to  deal  with  ectopic  gestation.  The  discharge  of  liquor 
amnii  or  of  decidua,  if  at  the  same  time  Ave  can  ascertain  that  the 
uterus  is  empty,  makes  it  sure.  Sometimes  we  can  prove  the  empti- 
ness of  the  uterus  by  bringing  the  index-finger  through  the  soft,  open 
cervix.  In  other  cases  we  come  to  the  same  conclusion  by  the  use  of 
the  sound,  which  enters  with  the  greatest  ease  and  can  be  turned  in 


DISEASES    OF    THE    GENITAL    ORGANS.  311 

all  directions  without  meeting  with  any  resistance.  But  we  would  not 
dare  to  use  the  sound  until  we  have  felt  a  round  or  oblong,  elastic, 
soft,  and  sensitive  tumor  outside  of  the  uterus.  Even  then  the  sound 
should  be  used  with  the  greatest  possible  gentleness,  in  order  not  to 
call  forth  contractions  of  the  fetal  sac  and  thereby  perhaps  cause  a 
rupture  or  a  tubal  abortion,  which  in  several  cases  has  proved  fatal. 

For  the  same  reason  it  is  contraindicated  to  use  the  curette  for 
obtaining  some  of  the  uterine  decidua.  In  the  menstrual  decidua 
there  are  also  large  cells,  but  by  far  not  so  large  as  in  pregnancy. 

In  making  the  differential  diagnosis  of  a  tumor,  we  should  think  of 
chronic  or  acute  salpingo-oophoritis,  but  as  a  rule  the  history  will  differ 
sufficiently  to  avoid  a  mistake.  After  the  middle  of  the  fifth  month  we 
may  be  able  to  hear  the  fetal  heart-sound  outside  of  the  uterus.  We 
may  be  able  to  hear  a  souffle  in  two  distinct  places, — over  the  side  of 
the  uterus  and  over  the  fetal  sac.  We  may  be  able  to  feel  fetal  parts. 
In  more  advanced  cases  the  foetus  is  felt  much  nearer  the  tips  of  the 
examining  fingers  than  when  the  uterine  wall  lies  between  it  and  the 
abdominal  wall. 

In  differentiating  the  case,  we  should  also  bear  in  mind  the  possi- 
bility of  a  combined  intra-uterine  and  extra-uterine  pregnancy,  of  which 
quite  a  number  has  been  reported. 

Sometimes  the  diagnosis  is  so  obscure  that  even  men  with  consid- 
erable experience  may  err.  Thus,  the  writer  and  another  gynaecologist 
made  the  diagnosis  of  ectopic  gestation  in  a  case  which,  when  I  oper- 
ated on  it,  proved  to  be  a  double  dermoid  ovarian  cyst  complicated 
with  pregnancy.  The  bony  parts  of  the  dermoids  had  been  taken  for 
fetal  bones,  Avhile  the  upper  part  of  the  uterus  was  covered  by  the 
tumors  and  appeared  small. ^ 

In  some  cases  the  round  ligament  may  be  felt,  and  its  relations  to 
the  sac  may  make  it  clear  that  the  tumor  is  situated  in  the  tube.  As 
long  as  the  fffitus  is  living  the  tubal  tumor  is  soft,  but  after  its  death  it 
becomes  hard  and  is  then  less  easy  to  diagnosticate. 

Prognosis. — The  prognosis  for  the  fcetus  is  bad,  wherefore  it 
deserves  so  much  the  less  to  be  taken  into  consideration.  The  danger 
for  the  mother  is  so  great  that  everything  should  be  done  in  her  favor, 
and  the  life  of  the  child  should  have  no  weight  unless  it  can  be  saved 
without  increasing  the  danger  incurred  by  the  mother.  The  prog- 
nosis for  both  mother  and  child  has,  however,  improved  enormously 
through  the  development  of  abdominal  surgery. 

Trecdment. — Opinions  of  competent  men  diiYer  so  much  in  regard 
to  the  best  treatment  of  ectopic  gestation  that  in  a  work  of  the  scope 
of  the  present  it  is  not  possible  to  enter  into  a  detailed  argument  with 

1  Garrigues,  "A  Case  of  Double  Ovariotomy  during  Pregnancy,"  The  Clinical 
Recorder,  vol.  i..  No.  2,  April,  1896,  p.  49. 


312  ABNORMAL    PREGNANCY. 

reference  to  the  reasons  alleged  for  one  or  the  other  mode  of  treat- 
ment. I  must  limit  myself  to  stating  how  in  my  opinion  the  different 
classes  of  cases  should  be  treated.  In  a  general  way  it  may  be  said, 
that  most  of  these  cases  are  so  serious  that  they  should  not  be  made 
the  occasion  of  a  display  of  surgical  dexterity,  but  that  the  simplest 
means  by  which  the  patient's  life  may  be  saved  should  have  the 
preference. 

The  method  of  killing  the  foetus  by  injecting  into  it  morphine  or 
other  poisons  must  be  looked  upon  as  entirely  obsolete.  In  the 
judgment  of  most  obstetricians  this  statement  also  applies  to  the  use  of 
electricity  for  the  same  purpose,  and  I  seize  this  opportunity  to  revoke 
nearly  all  that  I  in  former  years  said  on  the  subject.'^  Nevertheless, 
the  fact  that  all  other  methods  frequently  have  led  to  the  patient's 
death,  whereas  electricity  very  rarely  has  proved  fatal,  and  the  fact 
that  very  young  foetuses  may  be  totally  absorbed,  make  me  hesitate 
in  following  other  authors  in  their  absolute  condemnation  of  a  method 
that  has  given  excellent  results  in  the  hands  of  some  of  the  best 
American  obstetricians  and  gynaecologists.  But  with  our  present 
knowledge  of  the  possible  dangers  lurking  in  the  retention  of  a  dead 
foetus  in  the  tube,  and  with  our  greatly  improved  technique  in  cutting 
operations,  I  think  the  method  should  be  limited  to  the  first  two 
months  of  pregnancy.  It  seems  to  be  immaterial  whether  the  con- 
stant current  with  slow  interruptions  or  the  faradic  current  be  used, 
but  as  strong  a  current  as  the  patient  can  bear  without  an  anaesthetic 
should  be  applied,  the  sitting  should  not  be  shorter  than  ten  minutes, 
and  it  ought  to  be  repeated  daily  until  all  signs  of  pregnancy  have 
disappeared. 

The  first  efi'ects  of  electricity  are  to  cause  the  tumor  to  become 
much  smaUer  and  harder  by  absorption  of  liquor  amnii,  and  the 
breasts  to  become  flaccid. 

With  this  slight  and  very  limited  exception,  and  with  the  exception 
of  certain  cases  of  hsematocele,  the  treatment  of  ectopic  gestation  must 
be  surgical.^ 

The  operations  that  may  be  called  for  are  vaginal  incision  ;  lapa- 
rotomy, with  or  without  extirpation  of  the  fetal  sac ;  vaginal  panhys- 
terectomy ;  abdominal  panhysterectomy ;  incision  above  Poupart's 
ligament ;  perforation  of  the  fetal  sac  through  the  uterus  ;  cleaning  and 
suturing  of  the  tube. 

Vaginal  incision  is    indicated  in  cases  of  haematocele,   when  the 

1  Garrigues,  "  Electricity  in  Extra-uterine  Pregnancy,"  Trans.  Amer.  Gynaecol. 
Soc,  1882,  vol.  vii.  pp.  184-218. 

^  The  labor  of  the  author  has  been  much  facilitated  by  the  lucid  and  unbiased 
report  submitted  by  Paul  Segond  to  the  Periodical  Congress  of  Gynaecology, 
Obstetrics,  and  Paediatrics,  Paris,   1898. 


DISEASES    OF   THE    GENITAL    ORGANS.  313 

tumor  impinges  on  the   vagina ;    thrombus ;   suppuration  or   sepsis, 
when  easily  reached  from  the  vagina. 

Laparotomy  is  indicated,  (a)  with  removal  of  sac,  in  uncomplicated 
cases  until  the  end  of  the  fifth  month,  and  in  heematosalpinx  ;  (6) 
without  removal  of  sac,  in  haematocele  with  repeated  bleeding  ;  in  free 
intraperitoneal  hemorrhage ;  and  with  suppurating  sac  or  sepsis,  if 
the  tumor  is  more  abdominal. 

Vaginal  panhysterectomy  is  indicated  until  the  end  of  the  fourth 
month  if  the  other  set  of  appendages  is  diseased  or  the  uterus  is  the 
seat  of  a  myoma  or  cancer. 

Abdominal  panhysterectomy  is  indicated  under  the  same  circum- 
stances after  the  end  of  the  fourth  month ;  it  may  also  become  a 
necessity  in  order  to  control  hemorrhage. 

A  very  wide  scope  must  be  left  to  the  judgment  of  the  surgeon  in  the 
choice  of  the  treatment  best  adapted  to  the  particular  case,  in  which 
respect  the  condition  of  the  patient  claims  close  attention.  But  as  a 
guide  some  general  rules  may  be  laid  down  as  the  outcome  of  the 
united  experience  of  the  profession.  First  of  all  it  must  be  impressed 
on  the  mind  of  the  general  practitioner  that  the  treatment  of  ectopic 
gestation  is  nearly  always  surgical,  that  in  most  cases  prompt  interfer- 
ence is  called  for,  and  that  great  technical  difficulties  may  be  encoun- 
tered in  the  operation.  He  should,  therefore,  as  soon  as  he  has  made 
the  diagnosis,  or  even  if  there  is  only  a  suspicion  of  ectopic  gestation, 
secure  the  help  of  an  operating  gynaecologist  or  a  surgeon  familiar 
with  abdominal  work,  or  place  the  patient  under  the  care  of  some 
institution  in  which  that  kind  of  work  is  done. 

The  cases  may  be  divided  into  two  large  classes,  those  belonging  to 
the  first  five  months  of  pregnancy  and  those  that  come  under  obser- 
vation later,  when  there  are  or  might  be  distinct  signs  of  the  life  of  the 
foetus.  Each  of  these  classes  is  again  subdivided  into  uncomplicated 
cases  and  cases  complicated  by  the  death  of  the  foetus,  hemorrhage, 
suppuration,  or  sepsis. 

I.  Before  the  End  of  the  Fifth  Month. — In  uncomplicated  cases  the 
appendage  affected  should  be  removed,  and  the  other  set,  as  well  as 
the  uterus,  if  they  are  in  a  healthy  condition,  should  be  left  alone. 
The  operation  is  performed  exactly  like  an  ordinary  ovariotomy  or 
oophorectomy,^  but  the  operator  must  be  prepared  for  unusual  hemor- 
rhage, and  great  care  should  be  used  in  handling  the  sac,  as  its  rup- 
ture sometimes  has  proved  fatal. 

If,  on  the  other  hand,  the  second  set  of  appendages  is  diseased  or 
the  uterus  is  the  seat  of  myomatous  or  cancerous  degeneration,  the 
total  removal  of  the  uterus  with  both  appendages  is  said  to  be  indi- 
cated.    Still,  in  the  author's  opinion,  cancer  is  the  only  disease  serious 
^  Garrigues,  Diseases  of  Women,  third  ed. ,  pp.  566,  641. 


314  ABNORMAL   PREGNANCY. 

enough  to  warrant  such  an  addition  to  the  operative  interference. 
The  treatment  of  other  ailments  should  rather  be  deferred  till  after 
recovery  from  the  ectopic  gestation.  As  to  the  route  to  be  chosen, 
opinions  differ,  some  preferring  vaginal  and  others  abdominal  section. 
In  a  general  way  it  may  be  said  that  until  the  end  of  the  fourth 
month,  when  the  pregnant  uterus  would  reach  about  three  fmger- 
breadths  over  the  symphysis  pubis,  most  modern  gynaecologists  prefer 
the  vaginal  method,^  but  after  that  time  abdominal  hysterectomy^  is 
the  only  possible  way  to  do  the  operation,  and  even  before  that  time, 
in  an  operation  in  which  hemorrhage  plays  so  great  a  part,  in  the 
writer's  opinion  laparotomy  is  preferable. 

As  we  have  said,  if  only  one  side  is  affected,  as  a  rule,  the  adnexa 
of  this  side  should  be  removed  and  nothing  else  ;  but  there  may 
be  such  extensive  adhesions  or  the  hsemostasis  may  offer  such  dif- 
ficulties that  it  becomes  necessary  to  remove  the  uterus  and  both 
sets  of  appendages.  In  general,  supravaginal  amputation  deserves 
the  preference  to  total  extirpation  of  the  uterus,^  except  in  cancer 
cases. 

If  the  fetal  sac  in  ectopic  gestation  is  intraligamentous  or  sub- 
peritoneal, so  that  no  pedicle  can  be  formed,  the  best  method  is  first 
to  tie  the  ovarian  vessels  in  the  infundibulopelvic  ligament,  then  the 
anastomosis  of  the  ovarian,  uterine,  and  funicular  arteries,*  to  make 
a  superficial  incision  through  the  peritoneal  cover  in  a  place  where 
there  are  no  vessels,  enucleate  the  sac  from  its  peritoneal  pouch,  and 
treat  the  cavity  left  as  in  other  cases  of  enucleation.^  Generally,  the 
abdominal  wound  may  be  closed  and  no  drainage  is  needed 

In  cases  of  interstitial  pregnancy  Dr.  Howard  Kelly,  of  Baltimore, 
has  proposed  to  dilate  the  cervix,  introduce  a  uterine  sound  through 
it,  and  perforate  the  fetal  sac.  If  laparotomy  has  been  performed,  the 
other  hand  introduced  through  the  wound  steadies  the  sac  from 
without.  If  the  sac  in  interstitial  pregnancy  has  ruptured  and  the 
condition  of  the  patient  is  fairly  good,  efforts  may  be  made  to  clear  out 
the  sac  and  suture  it.  Active  hemorrhage  is  controlled  by  ligating  the 
ovarian  and  uterine  arteries  of  the  affected  side,  or  in  a  more  serious 
case  by  first  throwing  a  rubber  tube  around  the  uterus  below  the  sac. 

The  complications  that  may  influence  the  treatment  in  these  early 
cases  are  hemorrhage,  suppuration,  or  sepsis. 

The  importance  of  the  hemorrhage  depends  entirely  upon  the 
place  in  which  it  takes  place  and  the  amount  of  blood  lost.  A  simple 
hcematosalpinx  may  be  enucleated  and  removed  with  the  same  facility 
as  a  common  tube  containing  a  fetal  sac.     Nay,  even  the  tube  has  been 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  510. 
2  Ibid.,  p.  518.  Mbid.,  p.  525. 

Mbid.,  p.  58.  ^  Ibid.,  p.  526. 


DISEASES    OF   THE    GENITAL    ORGANS.  315 

saved.  Both  in  vaginal  and  abdominal  operations  the  tube  contain- 
ing the  blood  has  been  incised,  cleaned,  and  sewed  up  again. 

But  this  seems  to  be  carrying  conservative  surgery  too  far,  since 
the  patient  might  again  be  placed  in  the  same  predicament.  She 
may  be  glad  to  come  out  of  her  present  dangerous  condition  at  the 
cost  of  a  tube  which  might  endanger  her  life  afterwards. 

A  hcematoma  may  be  treated  by  simple  vaginal  incision  and  removal 
of  what  comes  off  easily. 

In  hcematocele  it  is  best  to  give  nature  plenty  of  time  to  form  the 
roof  over  the  blood  that  separates  it  from  the  peritoneal  cavity. 

The  patient  should  be  kept  very  c|uiet  in  bed,  an  ice-bag  should  be 
applied  over  the  symphysis,  unless  her  vitality  is  low,  and  pain  should 
be  relieved  by  opiates. 

If  the  tumor  does  not  become  absorbed  within  a  month  or  grows 
in  size,  it  is  best  to  introduce  a  posterior  vaginal  blade,  pull  the  cervix 
down  with  a  bullet-forceps,  make  a  straight  incision  in  the  median 
line  and  dilate  the  wound  bluntly  ;  or  to  make  a  transverse  incision 
behind  the  cervix,  adding  a  perpendicular  one  down  from  the  middle 
of  the  first  to  the  bottom  of  Douglas's  pouch,  and  empty  the  sac  very 
gently  with  the  finger,  a  blunt  curette,  or  a  common  teaspoon.^ 

One  should  be  satisfied  when  the  foetus  and  some  clots  have  been 
removed.  Too  energetic  cleaning  might  start  new  hemorrhage.  If 
there  is  no  bleeding  a  thick  soft-rubber  tube  wound  with  iodoform 
gauze  is  inserted,  but  if  it  bleeds  some  it  is  safer  to  tampon  for  twenty- 
four  hours  or  more  and  introduce  the  tube  later,  and  then  pack  the 
vagina  loosely.  In  the  beginning  the  dressing  is  changed  daily  and 
some  mild  antiseptic  solution  used  for  irrigation. 

If  the  extravasation  cannot  be  reached  from  the  vagina,  laparotomy 
should  be  performed.  This  may  be  done  in  two  ways,  the  subperi- 
toneal or  the  transperitoneal  method.  In  the  subperitoneal  method  an 
incision  is  made  above  and  parallel  to  Poupart's  ligament,  the  peri- 
toneum lifted  up,  and  an  incision  made  into  the  sac  without  entering 
the  peritoneal  cavity.  If  this  is  opened  accidentally,  the  opening 
should  be  enlarged  and  tamponed  with  iodoform  gauze  for  twenty-four 
hours,  until  adhesions  have  formed.  Then  the  gauze  is  removed  and 
the  tumor  incised.  The  cavity  once  emptied,  a  counter-opening 
should  be  made  in  the  vaginal  vault  and  through-drainage  established. 

Transperitoneal  laparotomy  is  performed  in  the  median  line.  If 
possible,  the  sac  should  be  stitched  to  the  parietal  peritoneum  and 
drained.  But  if  there  is  no  separate  sac,  or  if  it  is  so  brittle  that  the 
sutures  tear  out,  all  we  can  do  is  to  wash  out  the  cavity  with  sterilized 
water  or  Thiersch's  solution  and  drain  with  iodoform  gauze  through 
the  abdominal  wall. 

^  Garrigues,  Diseases  of  Women,   third  ed.,  pp.  510,  690. 


316  ABNORMAL    PREGXANCY. 

When  once  the  vaginal  incision  is  made,  the  whole  pelvis  can  be 
palpated,  and  if  the  operator  so  wishes  he  may  remove  the  append- 
ages on  the  affected  side,  leaving  the  uterus  and  the  other  set  of 
appendages  ;  or  he  may  remove  all. 

Laparotomy  is  more  dangerous,  but  in  cases  of  repeated  bleeding 
into  the  sac,  that  is  the  operation  to  be  preferred,  since  it  offers  much 
greater  facilities  for  dealing  with  the  source  of  the  hemorrhage. 

The  worst  of  abdominal  hemorrhages  is  the  non-encysted,  cata- 
clysmic, intraperitoneal  hemorrhage,  which  may  lead  to  almost  instant 
death.  In  a  case  that  was  operated  on  ten  minutes  after  a  rupture 
of  the  Fallopian  tube  a  quart  of  blood  had  already  accumulated  in  the 
peritoneal  cavity.  In  that  class  of  cases  the  only  available  remedy  is 
immediate  laparotomy.  By  turning  out  clots  and  liquid  blood  the 
operator  makes  his  way  as  rapidly  as  possible  to  the  internal  genitals, 
where  in  most  cases  he  will  find  a  ruptured  tube,  which  he  removes. 
After  that  he  cleans  the  peritoneal  cavity,  wipes  it  dry,  and  closes  it  in 
the  most  expeditious  way,  which  is  to  insert  silkworm-gut  sutures 
through  the  whole  thickness  of  the  abdominal  wall,  inclusive  of  the 
peritoneum.  After  that  every  effort  should  be  made  to  raise  the 
vitality  of  the  patient,^  and  to  increase  the  bulk  of  blood  circulating 
through  her  body  by  subcutaneous  or  intravenous  injection  of  normal 
salt  solution. 

If  the  contents  of  the  fetal  sac  suppurate  or  become  sepAic,  the 
tumor  becomes  softer,  the  temperature  rises,  the  pulse  becomes  fre- 
quent, the  skin  dry,  and  the  patient  complains  of  pain  in  the  loins 
and  the  legs.  The  sac  should  be  opened  by  vaginal  incision,  if  it  can 
be  reached  this  way.  Otherwise  laparotomy  with  marsupialization  or 
counter-opening  in  the  vagina  is  indicated.- 

11.  After  the  Fifth  Month. — If  the  patient  comes  under  observa- 
tion at  a  time  when  the  child  is  viable,  laparotomy  should  be  per- 
formed at  once,  with  the  hope  of  saving  both  mother  and  child.  As 
a  rule,  the  fetal  sac,  after  being  surrounded  by  absorbent  pads,  is 
simply  opened,  the  child  extracted,  the  edges  of  the  sac  stitched  to 
the  parietal  peritoneum,  the  placenta  left  undisturbed  until  it  is  loose, 
which  takes  from  two  to  four  weeks,  and  the  sac  filled  loosely  with 
iodoform  gauze,  which  is  renewed  daily,  and  at  the  same  time  the  sac 
is  irrigated  with  sterilized  water  or  some  mild  antiseptic. 

To  this  general  rule  there  are  three  exceptions.  First,  if  we  have 
to  deal  with  a  tubal  or  ovarian  pregnancy  and  the  sac  seems  to  be 
removable,  it  should  be  taken  away.  Second,  if  there  is  a  partial 
loosening  of  the  placenta,  causing  uncontrollable  hemorrhage,  the 
placenta  must  be  totally  removed  and  hsemostasis  sought  to  be 
1  Garrigues,  Diseases  of  Women,  third  ed.,  pp.  225,  226. 
Mbid.,  pp.  660,  703. 


DISEASES    OF   THE    GENITAL   ORGANS.  317 

obtained  by  ligation  or  circumvention  of  vessels,  the  thermocautery,  or 
Mikulicz's  tampon.^  Third,  if  it  is  a  secondary  abdominal  pregnancy, 
when  the  original  sac  has  ruptured  and  the  foetus  lies  free  in  the 
abdominal  cavity,  there  is  no  sac  to  stitch  to  the  abdominal  wall. 
After  extraction  of  the  child,  the  upper  part  of  the  wound  should  be 
closed  and  the  placenta  covered  with  strips  of  iodoform  gauze,  the 
ends  of  which  are  led  out  through  the  lower  angle  of  the  wound. 
The  irritation  produced  by  the  gauze  causes  adhesions  to  form,  so  that 
the  placenta  comes  to  lie  in  a  sac  walled  off  from  the  peritoneal  cavity 
but  open  on  the  anterior  abdominal  wall.  This  packing  ought  to  be 
left  undisturbed  as  long  as  the  general  condition  of  the  patient  war- 
rants it.  The  mummification  of  the  placenta  may  be  furthered  by 
covering  it  with  dry  benzoate  of  sodium. 

If  the  child  is  not  yet  viable,  our  conduct  must  depend  on  circum- 
stances. If  the  patient  is  in  a  precarious  condition  or  cannot  be 
watched,  it  is  necessary  in  her  interest  to  sacrifice  the  child  and  per- 
form laparotomy  at  once.  If,  on  the  other  hand,  she  feels  well  and 
can  be  under  constant  observation,  it  is  humane  to  give  the  child  a 
chance.  The  operation  should  then  be  postponed  till  the  seventh, 
eighth,  or  ninth  month — the  longer  the  better,  but  should  under  all 
circumstances  be  performed  before  false  labor  begins,  when  the  child 
is  particularly  liable  to  succumb  and  the  mother  is  in  the  most 
unfavorable  condition.  In  the  mean  time  she  should  be  kept  quiet, 
pain  should  be  relieved  with  opium,  and  the  operation  postponed  unless 
internal  hemorrhage  necessitates  immediate  laparotomy.  Before  labor 
sets  in  the  child  should  be  removed,  the  sac  being  stitched  to  the 
abdominal  wall  and  the  placenta  left  in. 

If  at  this  period  of  gestation  the  sac  ruptures  and  hemorrhage 
occurs,  be  it  cataclysmic  or  slow,  laparotomy  should  be  performed  at 
once,  the  bleeding  point  secured,  and  the  sac  stitched  to  the  abdominal 
wall.  But  if  the  bleeding  comes  from  the  placenta,  it  may  be  neces- 
sary to  remove  this. 

Cases  of  suppurative  peritonitis  are  treated  in  the  same  way. 

Partial  Removal  of  Sac. — Instead  of  removing  the  whole  sac  or 
leaving  it  altogether,  as  much  of  it  as  can  be  got  loose  without  causing 
hemorrhage  or  prolonging  the  operation  unduly  may  be  cut  off,  and 
the  remainder  stitched  to  the  abdominal  wall,  or  folded  together  over 
the  placenta  and  closed  with  sutures  after  a  counter-opening  has  been 
made  in  the  vagina. 

Dead  Child. — If  the  child  is  dead,  the  conduct  differs  according  to 
the  time  elapsed  since  its  death.  If  it  died  recently,  it  is  best  to  wait 
in  order  to  give  the  placenta  as  much  time  as  possible  to  undergo 
involution.     The  operation  ought,  however,  to  be  performed  before 

^Garrigues,  Diseases  of  Women,  third  ed.,  pp.  186,  526. 


318  '       ABNORMAL   PREGNANCY. 

menstruation  returns,  at  which  time  the  danger  of  hemorrhage  is  in- 
creased. The  longest  time  allowed  should  be  six  weeks.  The  oper- 
ation consists  in  laparotomy  and  marsupialization. 

If  the  child  has  long  been  dead,  the  same  operation  should  be 
performed  at  once. 

Old  Cysts. — Old  cysts  containing  a  foetus  should,  if  possible,  be 
extirpated.     If  not,  we  must  be  satisfied  with  marsupialization. 

In  these  old  sacs  the  remains  of  the  foetus  are  sometimes  so 
adherent  that  they  cannot  be  removed  without  injury  to  viscera.  Then 
they  should  be  left  and  the  sac  drained  and  irrigated  until  the  fetal 
parts  become  loosened. 

Suppurating  Sacs  with  Fistulous  Tracts. — If  a  suppurating  cyst  has 
opened  through  the  abdominal  wall  or  the  vagina,  the  opening  may 
be  enlarged  with  the  knife  and  blunt  dilatation.  If  the  abscess  com- 
municates with  the  rectum,  it  is  best  to  make  a  counter-opening 
through  the  abdominal  wall  or  the  vagina.  If  it  opens  into  the  bladder, 
a  small  foetus  may  be  removed  through  the  dilated  urethra ;  for  the 
removal  of  a  larger,  an  incision  is  made  from  the  vagina, — artificial 
vesicovaginal  fistula, — or  suprapubic  cystotomy,  and  perhaps  even 
laparotomy,  may  become  necessary. 

Repeated  Pregnancy. — An  ectopic  gestation  may  be  followed  by 
another  ectopic  gestation  or  by  normal  pregnancy.  This  fact  has  a 
bearing  on  the  treatment  in  several  ways.  It  teaches  us  not  to  com- 
mit unnecessary  mutilations  which  would  render  future  impregnation 
impossible.  On  the  other  hand,  it  is  an  incentive  to  operate  on  old 
cases,  even  when  they  are  in  a  dormant  condition,  as  old  cysts  are 
liable  to  suppurate  when  a  new  pregnancy  supervenes. 


CHAPTER  VII. 

SYSTEMIC  DISTURBANCES  DUE  TO  PREGNANCY. 

§  1.  Hyperemesis,  Severe  or  Uncontrollable  Vomiting. — As  we 
know,  some  degree  of  vomiting  is  so  common  in  pregnant  women  that 
it  is  even  counted  among  the  signs  of  pregnancy.  This  physiological 
vomiting  is  not  severe,  stops  usually  about  the  middle  of  gestation, 
and  does  not  affect  the  general  health.  The  patient  retains  her  appe- 
tite and  does  not  lose  in  weight.  The  pathological  vomiting  is  a  very 
different  matter.  It  often  does  not  begin  before  the  second  half  of 
pregnancy ;  it  may  take  such  proportions  that  the  woman  cannot 
retain  a  particle  of  food  ;  and  since  the  food  that  should  sustain  her 
body  is  ejected,  nutrition  suffers,  she  grows  thin  and  loses  her  strength. 


SYSTEMIC    DISTURBANCES    DUE   TO    PREGNANCY.  319 

The  pulse  becomes  weak  and  oedema  may  appear,  especially  around 
the  ankles.  Her  mental  force  diminishes  and  she  becomes  despond- 
ent. The  amount  of  urine  secreted  in  twenty-four  hours  is  reduced. 
Finally,  she  may  die  of  inanition. 

Etiology. — Sometimes  a  displacement  of  the  uterus — either  ante- 
flexion or  retroflexion — or  an  over-distention,  as  we  find  it  in  hy- 
dramnion  or  twin  pregnancy,  may  be  the  cause.  In  other  cases  there 
may  be  present  a  disease  of  the  stomach,  such  as  ulcer  or  cancer, 
which  under  the  influence  of  pregnancy  takes  a  new  development. 
But  most  commonly  no  such  material  changes  can  be  found,  and 
then  the  disturbance  is  looked  upon  as  a  reflex  neurosis  due  to  the 
growth  of  the  uterus  and  pressure  on  nerves  in  its  wall  or  in  its 
surroundings. 

Prognosis. — Most  cases  are  quite  amenable  to  treatment  and  of 
short  duration ;  but  others  constitute  a  complication  that  threatens 
the  patient's  life,  resists  all  medical  treatment,  and  calls  for  the  arti- 
ficial interruption  of  pregnancy  as  the  only  means  of  saving  the 
woman. 

Treatment. — If  there  is  a  displacement  of  the  womb,  it  should  as  far 
as  possible  be  corrected.  A  retroflexed  uterus  may  be  replaced  and 
kept  in  place  with  a  pessary.  If  the  anteflexion  passes  normal  limits, 
the  patient  should  be  kept  in  the  dorsal  position.  A  gentle  pressure 
may  be  exercised  for  an  hour  once  or  twice  a  day,  either  with  the 
patient's  own  hand  or  with  a  towel  rolled  into  a  cylinder;  or  a  Gariel's 
air  pessary  may  be  inflated  in  the  vagina.  Diseases  of  the  stomach 
should  be  treated  according  to  the  rules  of  medical  practice.  If  there 
are  granulations  at  the  os,  they  should  be  touched  with  lunar  caustic 
in  substance  or  in  a  strong  solution  (1  to  8  or  10).  Sometimes 
immediate  relief  has  been  obtained  by  Copeland's  method,  which 
consists  in  the  dilatation  of  the  os  and  the  lower  part  of  the  cervical 
canal  by  means  of  the  index-finger  of  one  hand  while  counter-pres- 
sure is  made  on  the  fundus  with  the  other.  The  irrigation  of  the 
stomach  has  also  arrested  vomiting  as  by  magic,  and  the  application 
of  an  ice-bag  to  the  neck  has  given  good  results.  Likewise  electricity, 
either  the  faradic  or  the  galvanic  current.  One  pole  is  applied  to  the 
course  of  the  pneumogastric  nerve  on  the  side  of  the  neck,  and  the 
other  to  the  pit  of  the  stomach.  The  application  should  be  made  daily 
for  five  minutes.  Since  the  disease  is  most  commonly  of  nervous 
origin,  hypnotism  may,  perhaps,  gain  an  easy  victory. 

In  common  cases  I  prescribe  first  bismuth  : 

R    Bismuthi  subnitrat. ,  ^ii  (8  grammes)  ; 
Magnesife  carbonat., 

Sacchari  albi,  aa  5ss  (15  grammes). — M. 
Sig. — A  rounded  teaspoonful  in  water  three  times  a  day. 


320  ABNORMAL   PREGNANCY. 

If  that  does  not  help,  I  use  iodine : 

B    Tinct.  iodi,  fl^ss  [2  grammes)  ; 
Potass,  iodidi,   ^ss  (2  grammes  ; 
Aqute  dest. ,   §iv  (120  grammes). — M. 
Sig. — A  teaspoonful  every  two  hours  mixed  with  a  tablespoonful  of  Avater. 

Often  cocaine  (J  grain — 15  milligrammes — every  hour)  has  an  ex- 
cellent effect. 

Sometimes  hydrocyanic  acid  in  the  following  mixture  is  good. 

R    Ac.  hydrocyan.  dilut. ,    ^ss  (2  grammes)  ; 
Ac.  citrici, 

Sodii  bicarbonat. ,  aa  ^ii  (8  grammes)  ; 
Syrup,  rubi  idsei,   5  ss  (15  grammes)  ; 
Aqua?  dest.,  q.  s.  ad  Jvi  (180  grammes). — M. 
Sig. — A  tablespoonful  every  two  hours. 

Then  oxalate  of  cerium  (gr.  v — 30  centigrammes — in  a  capsule  t.  i. 
d.),  orexine  (gr.  ii-iv — from  12  to  25  centigrammes — t.  i.  d.),  bromide 
of  potassium  or  sodium  (gr.  xv — 1  gramme — t.  i.  d.),  creosote  (iTLi-iii 
— from  6  to  20  centigrammes — in  a  teaspoonful  of  glycerin),  salicin 
(gr.  V — 30  centigrammes — t.  i.  d.  in  a  capsule),  ethereal  tincture  of 
opium  (tinct.  opii  deodorata,  ^xx — 1  gramme — t.  i.  d.),  phosphorus, 
asafoetida,  valerian,  or  liquor  arsenicalis  Fowleri  (n^i — 6  centigrammes 
— every  three  hours),  vinum  ipecacuanhae  (n^i — 6  centigrammes — 
every  hour),  may  be  tried. 

It  is  needless  to  say  that  the  bowels  should  bs  moved  if  they  are 
constipated,  and  some  judgment  should  be  used  in  the  choice  of  an 
aperient.  Nauseous  oil  or  salts  are  out  of  the  question.  A  pill,  as  a 
rule,  is  preferable  on  account  of  its  small  bulk  ;  or  some  of  the  made-up 
medicines,  such  as  Tarrant's  Seltzer  Aperient,  Abbey's  Salt,  Red  Raven 
Split,  or  solution  of  magnesium  citrate,  which  have  been  made  palatable 
by  the  pharmacist's  art,  should  be  tried. 

The  diet  is  of  great  importance,  and  the  physician  should  sedu- 
lously consult  the  patient's  likes  and  dislikes.  As  a  rule,  ice-cold  milk 
is  borne  better  than  anything  else,  but  sometimes  it  must  be  pep- 
tonized "  by  the  cold  process,"  dissolving  the  contents  of  one  of  Fair- 
child's  peptonizing  powder  tubes  in  a  pint  of  fresh  milk.  Some  can 
take  koumyss  or  zoolac,  products  produced  by  the  fermentation  of 
milk.  Sometimes  a  small  quantity  of  meat  with  bread  and  butter — 
for  instance,  a  delicate  ox-tongue  or  ham  sandwich— ^is  grateful  to  the 
patient  and  is  retained.  As  to  drinks,  nothing  can  be  equal  to  sips  of 
iced  champagne,  and,  when  that  cannot  be  procured,  other  alcoholic 
drinks,  especially  light  iced  wine  mixed  with  seltzer-water,  often  settle 
the  rebellious  stomach.    It  is  also  well  to  let  the  patient  swallow  small 


SYSTEMIC    DISTURBANCES   DUE    TO    PREGNANCY.  321 

lumps  of  ice,  and  sometimes  an  ice-bag  or,  on  the  contrary,  a  hot- 
water  bag,  or  a  compress  saturated  with  hot  alcohol,  mustard,  or  spirit 
of  camphor,  applied  to  the  pit  of  the  stomach,  proves  useful. 

The  different  invalid-foods,  such  as  Carnrick's  Soluble  Food,  Hor- 
lick's  Malted  Milk,  Nestle's  Food,  or  Tropon,  may  be  tried.  The  simul- 
taneous administration  of  digestives,  such  as  pepsin,  pancreatin,  inglu- 
vin,  or  diastase,  may  help  the  retention  and  assimilation  of  food.  If  the 
stomach  continues  to  be  rebellious,  it  may  be  allowed  to  rest  for  weeks 
by  resorting  to  rectal  alimentation.^  But  in  serious  cases  the  patient 
must  be  watched  most  carefully,  and  if  in  spite  of  all  our  efforts  she 
continues  to  lose  ground,  the  only  way  of  saving  her  life  is  to  induce 
premature  labor  or  even  artificial  abortion, 

§  2.  Ptyalism. — The  secretion  of  the  salivary  glands  may  increase 
during  pregnancy  to  such  an  extent  as  to  be  not  only  highly  uncom- 
fortable, but  even  dangerous.  A  quart  or  more  has  been  known  to  be 
gathered  in  twenty-four  hours,  the  patient  cannot  do  anything  but  spit, 
her  mouth  becomes  sore,  and  her  nutrition  suffers  under  the  loss  of 
the  albuminoid  fluid.     These  extreme  cases  are,  however,  rare. 

Treatment. — Astringents  have  no  effect ;  but  nervines,  such  as 
hromide  of  potassium,  belladonna,  cocaine,  and  opium,  have  a  restrict- 
ing power.  A  derivation  to  the  kidneys  by  the  administration  of 
juniper  tea  (berries  si,  boiling  water  Oi ;  dose  5ss-ii  two  or  three  times 
a  day)  has  also  effected  a  cure. 

§  3.  Constipation  or  diarrhoea  occurs  c^uite  commonly  in  preg- 
nancy and  should  be  treated  medicinally  and  dietetically  according  to 
general  rules. 

§  4.  Toothache  and  Caries  of  the  Teeth. — Besides  the  common 
toothache  of  a  purely  neuralgic  character,  caries  is  apt  to  set  in  or  get 
worse  during  pregnancy. 

§  5.  Cough. — Some  women  suffer  considerably  from  a  nervous 
cough  during  pregnancy,  which  should  not  be  neglected,  since  cough 
predisposes  to  miscarriage.  It  is  treated  with  opium,  belladonna, 
bromide  of  potassium,  hydrocyanic  acid  or  heroine  (tablets  with  gr. 
T¥'  tV^  i — 2-^'  ^'  1^  milligrammes). 

§  6.  Dyspnoea. — In  the  earlier  months  of  pregnancy  difficulty 
in  breathing  is  of  nervous  origin.  Later  it  is  due  to  mechanical 
pressure  of  the  growing  uterus.  The  patient  should  be  much  in  the 
open  air.  The  nervous  form  may  be  benefited  by  the  same  drugs 
as  nervous  cough  is.  In  the  mechanical  form  a  chief  point  is  the 
avoidance  of  all  constricting  bands  and  stiff  corsets.  Sometimes  iron 
and  manganese,  by  enriching  the  blood,  indirectly  relieve  the  short- 
ness of  breath. 

§  7.  Palpitation  may  be  a  conseciuence  of  the  hydraemic  condition 

^  GaiTigues,  Diseases  of  Women,  third  ud.,  p.  241. 
21 


322  ABNORMAL   PREGNANCY. 

characteristic  of  pregnancy  or  may  be  a  reflex  neurosis.  In  tlie  former 
case  it  should  be  treated  with  clialybeates,  manganese,  or  extract  of 
red  bone  marrow.  In  the  latter  monobromide  of  camphor  (gr.  iv — 
25  centigrammes — t.  i.  d.  in  capsules)  is  the  best  remedy. 

§  8.  Lipothymia. — Some  women  are  apt  to  have  fainting-spells, 
which  may  be  repeated  several  times  a  day.  Consciousness  is  lost,  but 
respiration  and  pulsation  continue.  During  an  attack  all  restricting 
bands  should  be  loosened ;  the  patient  should  be  aroused  by  sprinkling 
ice-water  upon  her  face,  slapping  her  naked  chest  with  a  towel  dipped 
in  the  same,  holding  strong  spirit  of  ammonia  or  carbonate  of  ammo- 
nium under  her  nose,  applying  hot-water  bottles  and  massage  to  the 
extremities.     In  the  intervals  a  fortifying  diet  and  tonics  are  indicated. 

§  9.  Insomnia. — Pregnant  women  often  complain  of  lying  awake 
or  being  annoyed  by  dreams,  which  disturbance  of  sleep  may  weaken 
them.  In  order  to  combat  it,  they  should  avoid  excitement  in  the 
evening  hours,  go  early  to  bed,  have  their  sleeping-room  well  ven- 
tilated, and  be  properly  covered.  Among  dietetic  means,  I  have  seen 
good  effect  of  a  pint  of  lager  beer  taken  towards  bedtime.  If  that 
does  not  suffice,  recourse  must  be  had  to  some  of  the  hypnotics, 
especially  trional  (gr.  xv — 1  gramme),  chloralamid  (gr.  xxx-xlv — from 
2  to  3  grammes),  sulphonal  (gr.  x — 60  centigrammes — repeated  every 
half  hour,  from  2  to  4  times),  chloral  hydrate  (gr.  xv — 1  gramme — 
repeated  every  half  hour,  from  2  to  4  times),  or  a  tablet  with  hydro- 
bromate  of  hyoscine  (gr.  -g-^o — 1  milligramme — by  the  mouth  or  gr. 
xio — 0-6  milligramme — hypodermically). 

§  10.  Headache. — Headache  often  troubles  the  pregnant.  Often 
it  is  due  to  ansemia,  but  more  commonly  it  is  of  purely  neuralgic 
nature.  First  of  all,  attention  should  be  paid  to  the  bowels,  insuring  a 
good  daily  movement.  The  anaemia  should  be  combated  with  Blaud's 
pills,  to  which,  if  the  patient  is  constipated,  aloes  may  be  added. 
Extract  of  red  bone  marrow  or  hemaboloids  have  even  a  better  effect. 
Symptomatically  I  use : 

R   Phenacetini,   3i  (4  grammes)  ; 
Sodii  bromidi,   3  ii  (8  grammes)  ; 
Caffeinae,  gr.  xxiv  (1.5  grammes). 
M.  et  div.  in  chart,  cerat.  no.  xii. 
Sig. — One  powder,  repeated  after  one  and  three  hours  if  necessary. 

§  11.  Neuralgia. — Besides  the  neuralgias  already  named,  such  as 
toothache  and  headache,  the  patient  may  suffer  from  pain  in  the 
breasts,  in  the  intercostal  spaces,  especially  the  fifth  on  the  left  side, 
in  the  groins,  shooting  down  along  the  front  of  the  thighs,  and  in  the 
uterus  itself.  Internally  bromide  of  potassium  or  sodium,  a  chalybeate, 
arsenic,  or  quinine  is  useful  in  cjuieting  the  irritated  nerves  and  com- 


SYSTEMIC    DISTURBANXES    DUE    TO    PREGXAN'CY.  323 

bating  anaemia  or  malaria.  Exceptionally  a  hypodermic  injection  of 
morphine  may  be  necessary.  Externally  a  mustard  plaster  or  fric- 
tion "with — 

R    Chloroformi,  ^ss  (15  grammes)  ; 

Spts.  ammoniag,   ^ii  (8  grammes)  ; 

Spts.  camphorte,  q.  s.  ad  ^ii  (60  grammes), 

often  gives  relief. 

§  12.  Chorea. — Chorea  is  especially  apt  to  appear  during  the  preg- 
nancy of  women  who  have  suffered  from  the  disease  in  childhood. 
Rheumatism  predisposes  to  it,  and  therefore  it  is  often  found  in  per- 
sons suffering  from  valvular  lesions  of  the  heart.  In  some  patients 
the  disease  has  a  mild  type ;  in  others  it  interferes  with  such  indispen- 
sable movements  as  chewing  and  deglutition  and  prevents  sleep,  when 
the  whole  nutrition  suffers  to  such  an  extent  that  a  fatal  end  may  be 
predicted  if  pregnancy  is  allowed  to  go  on,  or  that  insanity  may  follow 
after  delivery.  Sometimes  nature  herself  applies  the  supreme  remedy, 
the  disease  ending  in  abortion,  but  in  others  it  may  go  on  till  term. 
In  both  cases,  as  a  rule,  it  ends  shortly  after  the  uterus  has  been 
emptied,  which  plainly  shows  that  it  is  a  reflex  neurosis  brought  on 
by  the  irritation  of  the  nerves  of  the  uterus.  But  not  infrequently  it 
returns  in  subsequent  pregnancies. 

Treatment. — If  the  disease  develops  in  a  rheumatic  individual, 
warm  baths,  alkalines,  and  iodides  should  form  an  important  part  of  the 
treatment.  The  patient  should  sleep  in  a  blanket  without  sheets,  and 
the  diet  should  contain  but  little  meat  and  no  tea,  coffee,  chocolate, 
or  alcoholic  beverages.  If,  on  the  other  hand,  it  takes  its  origin  in  an 
anaemic  person,  albuminoid  food  and  a  generous  wine,  together  with 
iron,  manganese,  red  bone  marrow,  and  arsenic,  are  indicated.  Symp- 
tomatically  relief  is  afforded  by  the  bromides,  belladonna.  Calabar 
bean  (gr.  ii-iii — from  12  to  20  centigrammes — or  tinctura  physostig- 
matis,  n\,x — 60  centigrammes — t.  i.  d.),  chloroform,  chloral,  or  mor- 
phine. Chloral  has  been  given  in  doses  of  from  gr.  xv  to  gr.  xxx — 
— from  1  to  2  grammes — repeated  every  2  to  4  hours,  so  as  to  induce 
a  continuous  sleep,  from  which  the  patient,  however,  can  be  aroused 
when  loudly  spoken  to,  and  which  is  only  interrupted  in  order  to  give 
fluid  nourishment  five  or  six  times  a  day  and  attend  to  evacuations.^ 

If  nothing  else  helps,  premature  labor  or  even  abortion  should  be 
induced. 

§  13.  Tetany  ^  is  a  disease  of  the  nervous  system  that  sometimes 
affects  pregnant  and  puerperal  women.     Trousseau  distinguishes  three 

1  Louis  Lichtschein,  Medical  Record,  April  1,  1899. 

'  Garrigues,  "Obstetrical  Tetanus  and  Tetanoid  Contractions,"  Amer.  Jour. 
Obst.,  vol.  XV.,  No.  4,  October,  1882. 


324  ABNORMAL    PREGNANCY. 

forms, — a  benign,  a  middling,  and  a  grave  one.  In  the  benign  form  there 
are  only  local  manifestations,  a  tingling  sensation  in  hands  and  feet, 
stiffness,  and  pains.  The  hand  commonly  assumes  the  coniform  shape 
used  when  the  accoucheur  wants  to  pass  it  through  the  vagina ;  but 
sometimes  the  fingers  become  so  bent  that  the  nails  leave  impressions 
on  the  skin.  The  hand  is  bent  on  the  forearm,  and  this  on  the  arm. 
The  feet  are  in  strong  plantar  flexion  with  bent  toes  and  drawn-up 
heels,  while  the  legs  and  thighs  are  extended.  The  contraction  may 
simultaneously  occupy  the  upper  and  lower  extremities,  or  alternate 
between  the  two,  or  be  limited  to  either  of  them.  Most  commonly  the 
hands  are  affected.  The  convulsed  muscles  offer  resistance  when  one 
tries  to  change  the  position  of  the  parts  ;  and  if  he  succeeds,  the  fingers, 
when  let  loose,  resume  their  flexure,  or  exceptionally  they  remain  ex- 
tended, although  the  muscles  continue  to  be  contracted.  The  muscles 
are  hard  to  the  touch.  An  attack  may  last  from  five  minutes  to  two 
hours.  Towards  the  end  the  tingling  sensation  returns,  and  there- 
after the  muscles  again  become  movable  until  a  new  attack  occurs. 
The  whole  disease  lasts  several  days  or  as  much  as  three  months. 
At  any  time  during  its  course  contractions  can  be  brought  on  in  an 
extremity  by  compressing  its  chief  artery,  vein,  or  nerve.  There  is 
some  perversion  of  the  sense  of  touch.  An  object  held  in  the  closed 
hand  feels  as  if  it  were  wrapped  up  in  a  cloth.  When  walking  with 
naked  feet  on  the  floor,  the  patient  has  a  sensation  as  if  she  walked  on 
a  carpet.  In  the  second  degree  the  patient  feels  more  pain  and  has 
fever.  Different  parts  of  the  body  become  congested  and  the  extrem- 
ities are  oedematous.  The  muscular  contractions  extend  to  the  trunk 
and  face.  Trismus  and  difficult  deglutition  appear.  The  third  degree 
is  distinguished  only  by  the  prolongation  and  frequency  of  the  attacks. 

The  prognosis  is  good,  recovery  following  promptly  after  the  birth 
of  the  child. 

The  treatment  consists  in  tonics  and  antispasmodics, 

§  14.  Tetanus. — Tetanus  is  much  more  dangerous  than  tetany. 
During  pregnancy  it  appears  sometimes  with  an  intermittent  type  and 
starting  from  the  extremities,  like  tetany,  but  it  leads  to  general  con- 
vulsions and  death.  It  is  much  more  frequent  after  delivery,  where- 
fore we  will  postpone  the  consideration  of  it. 

§  15,  Paralysis. — Different  forms  of  paralysis  of  motor  or  sensory 
nerves  appear  so  much  oftener  in  pregnant  women  than  in  other 
women  of  their  age,  that  the  conclusion  is  warranted  that  pregnancy  in 
itself  predisposes  to  paralysis,  which  is  corroborated  by  the  restitution 
to  health  which  commonly  follows  some  time  after  labor.  The  most 
common  form  of  paralysis  is  hemiplegia.  Much  less  frequent  is  para- 
plegia, and  still  rarer  is  facial  paralysis,  amaurosis,  or  deafness.  The 
affection  begins,  as  a  rule,  in  the  later  months  of  pregnancy. 


SYSTEMIC    DISTURBANCES   DUE   TO    PREGNANCY.  395 

Etiology. — In  the  vast  majority  of  cases  the  paralysis  is  combined 
with  albuminuria,  and  is  therefore  looked  upon  as  due  to  uremia.  In 
others  it  is  attributed  to  anaemia,  plethora,  cerebral  hemorrhage  or 
congestion  of  the  brain,  hysteria,  rheumatism,  and  heart  diseases  with 
concomitant  embolus. 

Prognosis. — Compared  with  paralysis  under  other  conditions,  the 
prognosis  is  favorable.  If  it  is  only  of  reflex  origin,  as  a  rule,  it  ceases 
after  abortion  or  labor  at  term  ;  but  if  pregnancy  occurs  when  there  is 
an  organic  disease  of  the  nerve  centres,  this  usually  gets  worse  during 
pregnancy,  and  may  even  end  fatally. 

Treatment. — If  paralysis  occurs  in  a  person  affected  with  albu- 
minuria, the  case  is  so  grave  that  premature  labor  or  even  abortion 
should  be  induced  at  once.  If  on  the  other  hand  there  is  no  albu- 
min in  the  urine,  pregnancy  may  be  allowed  to  go  on  till  term  or  at 
least  till  the  child  is  in  a  good  condition  for  induction  of  premature 
labor,  but  both  mother  and  child  should  be  carefully  watched.  This 
is  especially  necessary  in  cases  of  paraplegia,  for  when  the  seat  of  the 
affection  of  the  spine  is  above  the  centre  of  uterine  contraction,  labor 
is  painless,  and  may  take  place  without  the  patient  knowing  it,  whereby 
both  she  and  the  child  are  exposed  to  considerable  danger,  which  even 
has  proved  fatal. 

Anaemia  should  be  combated  with  chalybeates,  manganese,  red 
bone  marrow,  and  arsenic.  Strychnine  is  contraindicated  during  preg- 
nancy on  account  of  its  oxytocic  effect ;  but  after  delivery  it  forms  the 
chief  remedy  together  with  electricity. 

§  16.  Convulsions. — Persons  suffering  from  epilepsy,  as  a  rule,  are 
no  worse  during  pregnancy  or  childbirth.  Often  they  are  even  better. 
They  should,  however,  not  be  allowed  to  nurse,  as  this  weakens  them, 
and  thus  may  aggravate  the  disease,  and  as  an  inherited  predisposition 
in  the  child  might  be  increased  thereby.  During  an  attack  the  child 
might  also  be  injured.  The  usual  treatment  with  large  doses  of  bro- 
mides is  well  borne. 

Hysterical  convulsions  as  well  as  other  forms  of  hysteria  may  be 
observed  in  pregnant  women.  If  they  have  been  hysterical  before  im- 
pregnation, occasionally  the  disease  ceases,  but  much  more  frequently 
their  hysteria  continues  and  is  aggravated  during  pregnancy.  The 
disease  may  also  take  its  first  beginning  during  pregnancy  or  a  painful 
labor.  Hysterical  pregnant  women  have  a  predisposition  to  become 
insane  after  confinement.  The  treatment  does  not  offer  any  serious 
deviation  from  that  outside  of  pregnancy,  except  that  strychnine  is  con- 
traindicated.    The  bromides  have  an  excellent  effect. 

By  far  the  most  common  form  of  convulsions  connected  with  preg- 
nancy, labor,  and  the  puerperium  is  eclampsia. 

Eclampsia  is  like  epilepsy  in  appearance,  but  differs  from  it  by  the 


326  '  ABNORMAL   PREGNANCY. 

rapid  succession  of  the  attacks  and  by  the  immediate  danger  to  Hfe  it 
entails. 

It  is  not  a  very  rare  disease,  since  it  is  found  once  in  330  cases  of 
labor,  and  on  account  of  the  horrible  spectacle  it  offers  and  the  well- 
known  dangers  linked  with  it,  those  who  are  connected  with  lying-in 
institutions  or  make  a  specialty  of  obstetric  practice  have  occasion  to 
witness  it  much  more  frequently.  It  occurs  most  frequently  during 
labor,  but  is  not  rare  during  pregnancy,  and  may  even  make  its  first 
appearance  after  delivery,  but  then,  as  a  rule,  during  the  first  few  days, 
and  quite  exceptionally  several  weeks  later. 

Symptoms. — In  picturing  this  formidable  disease,  we  shall  consider 
separately  the  premonitory  period,  the  attacks,  and  the  intervals  be- 
tween the  attacks. 

The  premonitory  stage  may  be  absent  altogether,  so  that  the  con- 
vulsions break  out  without  any  warning  in  an  apparently  well  woman  ; 
but  in  patients  who  are  under  constant  supervision  there  are  certain 
well-known  symptoms  which  call  attention  to  the  threatening  storm. 
The  patient  complains  of  headache,  pain  in  the  pit  of  the  stomach 
(cardialgia),  blurred  vision,  particularly  noticeable  in  reading  fine  type 
or  in  sewing,  black  spots  flitting  before  the  eyes,  and  dizziness. 

There  is  usually  some  oedema  of  the  subcutaneous  tissue.  That  of 
the  lower  limbs  and  vulva  has  comparatively  little  importance,  since 
it  may  be  produced  by  simple  mechanical  pressure  on  the  veins  in  the 
pelvis  ;  that  of  the  hands  and  fingers,  necessitating  the  removal  of 
rings  which  before  pregnancy  were  wide  enough,  is  more  suspicious, 
and  an  apparent  broadening  and  flattening  of  the  face,  due  to  infiltra- 
tion of  the  loose  connective  tissue  surrounding  the  eyes,  is  still  more 
significant. 

The  urine  in  nearly  all  cases  contains  a  more  or  less  considerable 
amount  of  albumin,  sometimes  so  much  that  the  whole  mass  solidifies 
by  boiling.     Its  secretion  is  also  much  reduced,  and  its  color  is  high. 

Sometimes  nausea  and  vomiting — although  they  have  not  been 
present  during  the  first  half  of  the  pregnancy,  when  usually  they  are 
most  common — appear.  The  patient  may  complain  of  restlessness 
and  insomnia,  and  her  friends  may  note  in  her  an  irritability  of 
temper  unknown  before. 

The  attack  proper  comes  on  suddenly,  the  first  thing  noticed  being 
little  twitchings  of  the  eyelids,  followed  by  tonic  and  clonic  spasms, 
extending  over  the  whole  face,  the  neck,  the  trunk,  and  the  extrem- 
ities. The  contraction  of  the  dorsal  muscles  predominating,  opis- 
thotonus is  developed,  while  the  arms  and  legs  are  being  alternately 
flexed  and  extended  in  rapid  succession,  and  the  thumbs  buried  in  the 
clinched  fists.  Even  the  musculature  of  the  uterus  partakes  in  the 
general  convulsions,  in  consequence  of  which  the  labor  proceeds  with 


SYSTEMIC    DISTURBANCES   DUE   TO    PREGNANCY.  327 

unusual  rapidity.  The  face,  at  first  pale,  soon  becomes  purple  or 
violet  and  bloated.  The  pupils  are  dilated  and  the  eyes  turned  up,  so 
as  to  expose  only  the  white.  The  respiration  is  temporarily  arrested. 
Often  the  urine  and  faeces  are  expelled  involuntarily.  The  tongue  is 
protruded,  and,  if  not  protected,  apt  to  be  bitten,  or  it  may  fall  back 
and  choke  the  patient.  The  mouth  is  full  of  foam,  and  when  air 
enters  the  lungs  it  produces  the  rales  of  pulmonary  oedema.  Finally, 
the  patient  may  die  suffocated  or  in  collapse  during  an  attack  or  in 
consecjuence  of  cerebral  hemorrhage.  Such  attacks  last  one  or  two 
minutes,  which  time,  however,  on  account  of  the  horror  of  the  situa- 
tion, seems  much  longer.  They  are,  as  a  rule,  repeated  from  a  few 
times  up  to  a  hundred. 

After  the  spasms  have  passed  the  patient  lies  in  a  comatose  condi- 
tion, with  stertorous  respiration  and  groans.  The  cyanosis  vanishes 
gradually,  respiration  becomes  regular,  free  perspiration  breaks  out, 
and  after  a  shorter  or  longer  lapse  of  time  the  patient  awakes,  feels 
tired,  complains  of  pain  in  the  muscles,  and  has  no  recollection  what- 
ever of  what  she  has  gone  through.  In  the  beginning  there  may  be 
hours  between  the  attacks  and  complete  return  to  consciousness  in  the 
intervals,  but  the  oftener  the  convulsions  are  repeated  the  shorter  be- 
come the  interspaces,  and  soon  the  patient  remains  in  coma  all  the 
time  between  the  spasms. 

As  a  rule,  convulsions  and  coma  cease  with  the  completion  of  labor, 
but  they  may  exceptionally  continue  for  days,  and  the  patient  may  die 
after  being  delivered,  death  being  due  to  insufficient  urinary  secretion, 
to  exhaustion  of  nerve  force,  to  pulmonary  oedema,  or  to  pneumonia, 
the  last  of  which  may  be  brought  about  by  the  entrance  of  substances 
from  the  alimentary  canal  into  the  lungs  (deglutition  pneumonia).  Fre- 
quently the  death  of  the  foetus  puts  an  end  to  the  attacks. 

The  pulse  ordinarily  becomes  rapid — up  to  150  beats  per  minute — 
hard  and  full.  If  it  becomes  weak  and  easily  compressible,  the  prog- 
nosis is  absolutely  bad. 

The  temperature  rises  with  the  frequency  and  duration  of  the 
attacks,  and  either  attains  a  great  height  before  death  or  subsides  rather 
rapidly  after  the  cessation  of  the  convulsions. 

After  the  convulsions  have  ceased,  unconsciousness  and  somno- 
lence generally  continue.  The  patient  is  restless  and  sensitive  to 
touch.     This  condition  may  continue  for  several  days. 

Not  infrequently  eclampsia  is  followed  by  attacks  of  mania,  which, 
however,  as  a  rule,  are  not  of  long  duration  and  end  in  recovery. 

Pathology. — Autopsies  on  patients  who  have  succumbed  to  eclamp- 
sia show  conditions  so  various  that  they  do  not  teach  us  much  in 
regard  to  the  true  nature  of  the  disease,  and  often  it  remains  doubtful 
whether  the  changes  found  should  be  looked  upon  as  cause  or  effect  of 


328  ABNORMAL    PREGNANCY. 

the  disease.  The  brain  is  usuaUy  anaemic  and  edematous,  and  some- 
times there  is  an  extravasation  of  blood  into  the  ventricles  or  at  the 
base.  Very  frequently  the  kidneys  are  in  a  state  of  congestion  or  of 
acute  or  chronic  nephritis.  Often  the  ureters  are  dilated.  But  in 
other  cases  no  trace  of  abnormalities  is  found  in  the  uropoietic  organs, 
while  in  the  liver  are  found  hemorrhagic  foci.  Liver  cells,  parts  of  the 
syncytium  of  the  villi  of  the  chorion,  and  endothelial  cells  of  the 
blood-vessels  have  been  found  forming  minute  emboli  far  away  from 
the  place  in  which  they  originated.  Sometimes  the  muscular  tissue 
of  the  heart  is  found  degenerated.  The  lungs  are  oedematous  or 
inflamed.     Not  rarely  the  pelvis  is  generally  contracted. 

Etiology. — Many  theories  have  been  advanced  to  explain  the  out- 
break of  eclampsia,  but  so  far  none  of  them  covers  all  cases.  There 
are,  however,  facts  which  doubtless  are  of  great  importance  in  the  pro- 
duction of  this  terrible  malady.  The  disease  is  much  more  common 
in  primiparae  than  in  those  who  have  borne  children  before.  It 
occurs  preferably  in  the  last  months  of  pregnancy  or  during  labor. 
Twin  pregnancy  predisposes  to  it.  As  a  rule,  it  ceases  after  delivery. 
Frequently  the  ureters  have  been  found  dilated.  Taking  all  these  facts 
together,  the  theory  has  been  advanced  that  the  convulsions  are  due 
to  2^^^essure  on  the  ureters,  a  theory  that  covers  many  cases,  but  not 
those  where  the  disease  breaks  out  during  the  puerperium,  when  all 
pressure  is  removed,  and  which  is  weakened  by  the  fact  that  ovarian 
and  uterine  tumors  much  larger  than  the  pregnant  uterus  do  not  give 
rise  to  eclampsia. 

The  almost  constant  occurrence  of  albuminuria,  the  diminution  in 
renal  secretion,  the  frequent  presence  of  nej^hritis,  and  the  greatly 
increased  amount  of  leucomaines  found  in  the  blood  of  those  affected 
with  eclampsia  have  led  many  to  look  upon  the  convulsions  as  caused 
by  retention  of  some  substance  that  ordinarily  is  eliminated  with  the 
urine  and  which  has  poisonous  qualities. 

A  third  theory  seeks  the  cause  in  the  ancemie  condition  of  the  brain, 
which  has  been  proved  experimentally  to  give  rise  to  convulsions  in 
animals.  Some  think  this  ischaemia  is  caused  by  the  hydrcemia  charac- 
teristic of  pregnancy  and  the  opposition  to  free  circulation  offered  by 
the  diseased  kidneys,  while  others  invoke  a  spastic  contraction  of  the 
blood-vessels  of  both  brain  and  kidney. 

Some  think  the  liver  is  the  organ  at  fault. 

The  increased  nervous  irritability  so  conspicuous  during  pregnancy 
has  without  doubt  much  to  do  with  the  production  of  the  disease  and 
may  combine  with  pressure,  toxaemia,  or  anaemia  to  produce  the  convul- 
sions. 

In  some  instances  heredity  seems  to  predispose  to  the  disease,  sev- 
eral members  of  the  same  family  falling  victims  to  it. 


SVSTEMIC    DISTURBANCES   DUE   TO    PREGNANCY.  329 

AtmospheriG  conditions  are  probably  not  without  influence  on  the 
production  of  eclampsia,  many  more  cases  occurring  in  damp,  cold 
weather  than  under  more  favorable  circumstances.  The  social  posi- 
tion and  the  constitution  of  the  patient,  on  the  other  hand,  seem  to  be 
without  importance.  Rich  and  poor,  strong  and  weak,  well-nourished 
and  half-starving  women  are  ecfually  attacked  by  this  dangerous  foe, 
who  respects  the  palace  as  little  as  the  hovel. 

Of  late  the  theory  has  been  advanced  that  the  disease  is  of  microbio 
origin. 

Diagnosis. — The  diagnosis  of  eclampsia  liardly  offers  any  difficulty. 
Hysteria,  as  a  rule,  is  known  to  have  existed  before  the  patient  became 
pregnant.  The  unconsciousness  is  not  so  deep  and  protracted.  The 
attacks  do  not  follow  upon  one  another  with  such  rapidity.  After 
the  attack  is  over,  the  patient  soon  rallies,  and  a  laughing  or  crying 
spell  offers  a  picture  entirely  different  from  eclampsia.  With  very 
rare  exceptions  epilepsy  is  known  to  have  been  present  before  the 
present  outbreak,  and  the  convulsions  are  not  repeated  with  such 
short  intervals. 

Prognosis. — The  prognosis  is  very  grave.  The  maternal  mortality 
is  at  least  14  per  cent.,  and  the  infantile  twice  as  great.  It  is  by  no 
means  rare  for  the  accoucheur  to  be  placed  in  the  unenviable  position 
of  losing  both  the  beings  whose  welfare  is  entrusted  to  his  care.  Even 
after  the  attacks  have  discontinued  the  patient  may  succumb.  There 
is  also  danger  of  apoplexy  leaving  her  an  invalid.  Eclampsia  is  often 
accompanied  by  hemorrhage  from  the  genital  canal.  It  predisposes  to 
puerperal  insanity,  and  sometimes  it  is  followed  by  Bright's  disease. 
Not  infrequently  the  albuminuria  leads  to  abortion.  The  death  of  the 
foetus  is  probably  due  to  insufficient  supply  of  oxygen  or  to  toxic  sub- 
stances transferred  to  it  from  the  mother.  Sometimes  it  partakes  in 
the  maternal  convulsions.  Finally,  the  mother  being  in  so  great  a 
danger,  the  foetus  is  apt  to  suffer  under  the  treatment  carried  out  for 
the  benefit  of  the  mother,  whether  surgical  or  medicinal. 

Treatment. — The  appearance  of  any  of  the  above-mentioned  pre- 
monitory signs — headache,  dizziness,  indistinct  vision,  pain  in  the  pit  of 
the  stomach,  restlessness,  insomnia,  etc. — should  put  the  accoucheur 
on  his  guard.  I  examine  the  urine  even  of  apparently  healthy  women 
once  a  month  during  pregnancy.  The  urine  should  preferably  be 
drawn,  so  as  to  avoid  admixture  with  vaginal  and  uterine  secretions. 
Traces  of  albumin  are  not  rarely  found  in  the  renal  secretion  of 
healthy  puerperae,  but  the  appearance  of  this  substance  is  so  ominous 
that  the  urine  should  thereafter  be  examined  much  more  frequently. 
If  it  contains  red  blood-corpuscles,  epithelial  cells  from  the  kidneys,  or 
casts,  the  condition  is  so  much  the  more  serious,  and  a  large  amount 
of  albumin  always  calls  for  active  interference. 


330  ABNORMAL   PREGNANCY. 

The  treatment  during  the  premonitory  period  is  very  eifective. 
The  writer  has  seen  many  cases  in  which  he  thinks  future  evil  was 
averted  by  timely  medication.  If  the  case  is  at  all  serious,  I  put  the 
patient  on  exclusive  milk  diet,  allowing  only  a  few  of  the  lightest 
crackers — "  sea  foam  " — to  be  taken  with  the  milk.  If  the  patient 
feels  perfectly  well,  I  consult  her  hunger  and  allow  her  after  having 
disposed  of  two  quarts  of  milk  per  day  to  eat  some  meat  and  a  little- 
bread.  I  let  the  patient  take  a  warm  bath  every  or  every  other  day, 
and  let  her  make  cold  applications  to  the  top  of  the  head  and  the 
forehead.  If  necessary  a  copious  movement  of  the  bowels  is  brought 
on  once  or  twice  a  day  by  a  saline  aperient.  Twenty  drops  of  tinc- 
tura  ferri  chloridi  are  given  in  a  mixture  four  times  a  day,  and  every 
night  the  patient  receives  a  small  dose  of  chloral  hydrate  (gr.  xv — 
1  gramme),  which  seems  to  have  a  direct  influence  in  diminishing  the 
amount  of  albumin  in  the  urine,  quiets  the  nervous  system,  and  in- 
duces sleep.  If  she  complains  of  headache,  I  give  her  my  headache 
powders  (p.  322).  If  the  urinary  secretion — or,  what  is  still  more  im- 
portant, the  amount  of  urea — is  abnormally  small,  I  prescribe — 

R    Decocti  tritici  (gss),   gviii  (240  grammes)  ; 
Potassii  acetatis, 
Potassii  bitartratis, 

Potassii  citratis,  aa  gii  (8  grammes). — M. 
Sig. — Shake  well.      A  tablespoonful  from  4  to  6  times  a  day. 

This  acts  both  as  a  diuretic  and  a  laxative.  Instead  of  the  warm 
bath,  some  prefer  a  vapor  bath  or  a  Turkish  bath.  Tincture  of  digi- 
talis is  also  much  used  as  a  diuretic. 

I  am  rather  reluctant  to  cause  abortion  or  induce  premature  labor. 
In  my  opinion  these  should  not  be  resorted  to  unless  there  is  evi- 
dence that  the  patient's  life  is  endangered,  especially  if  the  urine  is 
loaded  with  albumin,  if  there  is  severe  headache,  disturbed  vision,  or 
dizziness,  and  if  milder  remedies  remain  ineffectual. 

If  we  see  the  patient  first  during  the  attack,  we  give  chloroform  in 
order  to  cut  it  short  and  gain  some  time.  But  this  is  a  remedy  of 
which  it  is  not  well  to  make  a  protracted  use,  since  it  is  apt  to  cause 
an  acute  fatty  degeneration  of  the  heart,  to  which  the  patient  may  suc- 
cumb after  having  recovered  from  her  eclampsia,  and  we  have  other 
and  better  means  of  quieting  her  nervous  system. 

The  next  question  to  decide  is,  whether  we  should  bleed  the  patient 
or  not,  and  in  determining  it  the  accoucheur  should  be  guided  not  by 
any  doubtful  theory  as  to  the  nature  of  the  disease,  but  exclusively 
by  the  condition  and  constitution  of  the  patient.  If  she  is  robust, 
well-nourished,  and  has  a  full,  hard  pulse,  he  should  bear  in  mind 
that  the  subtraction  of  from  twelve  to  sixteen  ounces  of  blood  from 


SYSTEMIC   DISTURBANCES   DUE   TO    PREGNANCY.  331 

a  vein  at  the  bend  of  the  elbow  has  proved  decidedly  useful  in  such 
cases.  If,  on  the  other  hand,  the  subject  is  one  of  those  thin,  pale, 
weak  women  who  form  the  majority  of  the  female  population  of  our 
large  cities,  bleeding  is  contraindicated. 

The  next  step  is  to  influence  the  nervous  system  in  a  more  per- 
manent way  than  by  the  evanescent  sleep  produced  by  chloroform. 
For  this  purpose  three  drugs  vie  with  one  another, — chloral,  morphine, 
and  American  hellebore — veratrum  viride.  Chloral  hydrate  may  be 
given  in  enemas,  gr.  xv  to  xxx  (1-2  grammes),  repeated  every  quarter 
of  an  hour,  until  siiss  (10  grammes)  have  been  used  in  all.  Morphine 
may  be  given  hypodermically,  beginning  with  1|  grain  in  one  dose 
(sic),  repeated  if  after  some  hours  a  new  attack  follows,^  There  is  in 
this  disease,  as  often  observed,  a  tolerance  of  opium  which  allows  us 
to  use  toxic  doses. 

Tinctura  veratri  viridis  (Norwood)  is  also  used  in  heroic  doses  and 
may  also  be  administered  hypodermically,  beginning  with  n^x  and  re- 
peating it  every  quarter  of  an  hour,  half  hour,  or  full  hour  until  the 
pulse  is  soft  and  below  60,  and  thereafter  enough  to  hold  it  between 
60  and  70  per  minute.  Veratrum  viride  reduces  pulse  and  tempera- 
ture, causes  diaphoresis  and  diuresis,  and  relaxes  the  cervical  canal. 
It  is  perhaps  even  more  popular  in  America  than  the  morphine 
treatment. 

The  tongue  should  be  protected  against  injury  by  placing  a  flat 
wooden  stick  wound  with  flannel  between  the  teeth  and  above  the 
tongue. 

Diuresis  may  be  furthered  by  the  subcutaneous  injection  of  normal 
salt  solution,^  Avhich  at  the  same  time  serves  to  dilute  the  poison  cir- 
culating in  the  blood,  and,  if  venesection  is  used  or  spontaneous  hem- 
orrhage occurs,  offers  the  advantage  of  increasing  the  bulk  of  the  cir- 
culating fluid. 

If  there  is  much  anasarca,  the  wet  pack  is  very  useful  and  may 
be  combined  with  the  above-described  medicinal  treatment.  In  order 
to  avoid  sufl'ocation  of  the  child  in  case  it  should  be  born  while  the 
patient  is  in  the  pack,  three  separate  blankets  should  be  used.  They  are 
wrung  out  of  water  the  temperature  of  which  may  be  adapted  to  that 
of  the  patient,  using  it  cool  (80°  F.)  if  her  temperature  is  high  and  warm 
(from  100°  to  105°  F.)  if  the  sole  object  is  to  produce  perspiration. 
First  a  water-proof  sheet  is  laid  on  the  bed,  then  a  dry  woollen  blanket, 
then  the  three  wet  blankets,  one  of  which  surrounds  the  body  from 

^  This  is  a  specifically  American  method,  invented  by  Dr.  C.  C.  P.  Clark,  of 
Oswego,  N.  Y.  (see  American  Journal  of  Obstetrics,  1880,  vol.  xiii.  p.  533,  and 
1881,  vol.  xix.  p.  416),  which  of  late  has  been  adopted  with  great  success  in  Ger- 
many, without  giving  credit  to  its  originator. 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  225. 


332  ABNORMAL   PREGNANCY. 

the  neck  to  the  genitals,  and  one  each  of  the  extremities.  Finally,  the 
dry  blanket  is  wrapped  around  the  body,  leaving  the  space  between 
the  legs  free.  As  this  treatment  is  rather  weakening,  it  should  not  be 
used  longer  than  two  hours  at  a  time,  but  it  may  be  repeated  if 
necessary. 

If  oxygen  is  available,  it  is  well  to  let  the  patient  inhale  it.  In 
cases  of  pulmonary  oedema,  the  lungs  may  be  freed  by  dry-cupping  of 
the  chest  and  back.  When  the  patient  is  unconscious  and  unable  to 
swallow,  she  may  be  purged  by  mixing  a  drop  of  croton  oil  with  a 
little  butter  and  rubbing  it  on  the  tongue. 

A  question  of  paramount  importance  is  whether  and  when  labor 
should  be  induced.  Some  authors,  wanting  the  uterus  emptied  as 
soon  as  possible,  dilate  the  cervix  forcibly  and  make  deep  incisions  in 
it  in  order  to  be  able  to  extract  the  child  manually  or  with  the  for- 
ceps. The  writer,  on  the  contrary,  sides  with  those  wiio  wait  till  there 
is  beginning  labor,  but  then  he  anaesthetizes  the  patient  and  dilates  the 
cervical  canal  with  Barnes's  bags  or  with  the  fingers  according  to  Har- 
ris's method.  (See  Operations.)  When  the  cervix  is  obliterated  and 
the  OS  fully  dilated,  the  child  is  removed  by  means  of  forceps  or  version, 
operations  which  will  be  described  later. 

In  cases  where  the  cervix  was  not  dilatable  and  the  condition  of  the 
mother  was  desperate,  Caesarean  section  has  been  performed,  saving 
one-half  of  the  mothers  and  somewhat  less  than  half  of  the  children. 

The  above  pages  had  been  written  when  Prof.  W.  Stroganoff,  of 
St.  Petersburg,  published  his  wonderful  report  of  fifty-eight  cases  of 
eclampsia  without  a  death.^  Prof.  Stroganoff  considers  eclampsia  to 
be  an  acute  infectious  disease,  which  usually  runs  its  course  in  a  few 
hours,  seldom  exceeding  twenty-four,  and  still  more  infrequently  ex- 
ceeding forty-eight  hours  in  duration.  He  takes  chloroform  inhala- 
tion during  the  attacks  to  be  injurious  on  account  of  its  effect  on  the 
respiration.  During  the  attack  he  lets  the  patient  inhale  oxygen  and 
removes  all  weight  from  the  thorax.  After  the  first  convulsion  he 
injects  J  grain  (15  milligrammes)  of  hydrochlorate  of  morphine.  This 
is  repeated  in  an  hour,  or,  if  the  patient  is  unruly  and  has  muscular 
twitching,  earlier.  After  the  second  or,  in  bad  cases,  the  third  injec- 
tion, chloral  hydrate,  gr.  xx-xl  (from  1.30  to  2.60  grammes),  is  given 
by  the  mouth  or  by  the  rectum  every  six  to  ten  hours,  so  as  to  keep 
up  a  light  narcosis.  If  a  convulsion  threatens,  morphine  is  injected 
hypodermically.  Stroganoff  claims  that  the  combination  of  morphine 
and  chloral  is  more  effective  than  either  of  these  drugs  employed  alone. 

As  soon  as  the  uterus  can  be  emptied  without  doing  harm  it  ought 
to  be  done,  and  the  method  he  prefers  for  obtaining  dilatation  is  by 

1  Stroganoff,  Obstetrics,  vol.  iii.,  No.  2,  Feb.,  1901,  p.  49. 


SYSTEMIC    DISTURBANCES    DUE    TO    PREGNANCY.  333 

Champetier  des  Ribes's  bag  with  continuous  traction.  He  condemns 
hot  baths  and  packs  and  never  uses  venesection.  Besides  the  mor- 
phine and  chloral  he  uses  only  sodium  bromide.  Mucus  is  removed 
from  mouth  and  nostrils,  the  room  v^ell  ventilated,  and  all  irritation 
avoided.  If  a  vaginal  examination  has  to  be  made  or  the  urine  must  be 
drawn  or  the  genital  canal  cleaned,  the  patient  is  first  anaesthetized  with 
chloroform.  If  there  is  any  weakness  of  the  heart,  musk  or  sulphuric 
ether  is  given. 

The  treatment  has  also  a  good  effect  on  the  foetus,  since  Stroganoff 
had  an  infantile  mortality  of  only  11  per  cent.,  which  is  about  one- 
fourth  of  the  combined  statistics  of  German  obstetricians. 

In  a  later  article  ^  Stroganoff  has  increased  his  material  to  one  hun- 
dred and  thirteen  cases  with  six  deaths,  due  to  croupous  pneumonia, 
puerperal  sepsis,  or  the  moribund  condition  in  which  the  patients  were 
received. 

If  convulsions  continue  after  the  uterus  "is  empty,  the  above- 
described  treatment  is  continued,  and  at  this  stage  Zweifel  ^  extols  the 
effect  of  bleeding. 

§  17.  Insanity. — Mental  disease  is  much  more  common  after 
than  before  delivery,  and  will  be  described  among  the  affections  of  the 
puerperium.  But  even  during  pregnancy  the  mind  sometimes  becomes 
unbalanced.  The  tendency  to  fear  and  sadness  which  we  have  spoken 
of  as  a  not  infrequent  accompaniment  of  the  pregnant  condition  may 
degenerate  into  real  melancholia,  perverse  ideas,  hallucinations,  change 
of  character,  and  proneness  to  suicide.  The  patient  sometimes  refers 
to  some  imaginary  great  sin  she  has  committed,  indulges  in  lewd 
language,  or  makes  improper  proposals  to  persons  of  the  male  sex. 
Sometimes  she  develops  kleptomania  or  dipsomania. 

Insanity  of  pregnancy  is  much  more  common  among  women  be- 
tween thirty  and  forty  years  of  age  than  among  younger  women,  and 
occurs  more  frequently  in  primiparae  than  in  those  who  have  borne 
children.  Often  an  hereditary  disposition  is  undeniable,  the  same  con- 
dition having  appeared  in  several  members  of  one  family  ;  or  other 
neuroses,  such  as  epilepsy,  hysteria,  and  drunkenness,  being  found  in 
the  history  of  the  ancestors  of  the  patient.  In  some  women  insanity 
has  recurred  in  each  succeeding  pregnancy. 

The  disease  commonly  starts  in  the  third  or  fourth  month  and 
rarely  ceases  before  the  end  of  gestation. 

Taking  into  consideration  the  interests  of  mother,  child,  and  the 
community  at  large,  it  should  not  be  allowed  to  develop  further,  but 
forthwith  terminated  by  the  induction  of  artificial  abortion. 

^  Stroganoff,  Centralblatt  fur  Gynakologie,  1901,  vol.  xxv.,  No.  48,  p.  1312. 
^  Paul  Zweifel,    Lehrbuch   der   Geburtshiilfe,    fourth   ed.,   Stuttgart,    1895,   p. 
433. 


334  ABNORMAL   PREGNANCY. 

§  18.  Irritability  of  the  Bladder. -^Very  commonly  pregnant 
women  complain  of  a  frequent  desire  to  urinate.  In  the  beginning 
this  is  due  to  a  reflex  neurosis  ;  but  later,  when  the  uterus  grows,  it  is 
largely  caused  by  the  mechanical  pressure.  The  discomfort  may 
become  so  great  that  it  makes  the  patient  nervous  and  sleepless,  with 
impairment  of  the  general  health. 

The  patient  should  rest  for  an  hour  or  more  in  the  recumbent  posi- 
tion in  the  middle  of  the  day.  She  should  avoid  alcoholic  beverages, 
especially  beer.     Alkalines  and  narcotics  should  be  prescribed, — e.  g. : 

R    Tinct.  belladonnae,  gii  (8  grammes)  ; 
Liq.  potassBe,   5  i  (30  grammes)  ; 
Aquae  dest.,  q.  s.  ad  ^iv  (120  grammes). — M. 
Sig. — A  teaspoonful  in  a  wineglassful  of  water  three  times  a  day,  between  meals. 

Or,  if  the  urine  is  alkaline,  a  tablespoonful  of  the  saturated  solu- 
tion of  boric  acid  should  be  taken  three  or  four  times  a  day.  Sup- 
positories containing  one-third  of  a  grain  of  morphine  may  be  placed 
in  the  vagina  at  bedtime. 

§  19.  Enuresis. — Some  pregnant  women  cannot  retain  the  urine, 
which  constantly  dribbles  away,  irritating  the  skin.  An  abdominal  sup- 
porter often  gives  great  relief.  Of  remedies  commonly  prescribed  for 
the  weakness,  strychnine  and  ergot  are  contraindicated.  If  needed  the 
chemical  reaction  should  be  changed  by  means  of  alkalines  or  boric, 
phosphoric,  or  nitric  acid.  Belladonna,  small  doses  of  tincture  of  can- 
tharides,  turpentine,  rhus  aromatica,  Scutellaria,  and  bromide  of  potas- 
sium quiet  the  bladder,  and  iron  preparations  may  strengthen  it. 

§  20.  Retention  of  nrine  is  due  to  pressure  against  the  urethra. 
As  we  have  seen  above,  it  is  often  a  symptom  of  a  retroflexed  uterus, 
and  may  have  very  serious  consequences.  The  bladder  should  there- 
fore in  time  be  emptied  with  a  catheter,  a  retroflexed  uterus  must  be 
replaced  and  kept  in  place  with  a  pessary  and  an  abdominal  supporter, 
and  rest  in  the  recumbent  position  may  also  be  useful. 

§  21.  The  Kidney  of  Pregnancy  and  Nephritis. — The  examina- 
tion of  the  urine  of  pregnant  and  parturient  women,  apparently  in 
good' health,  has  shown  that  albuminuria  and  the  presence  of  form- 
elements  are  common  occurrences.  Small  amounts  of  albumin  are 
found  in  about  four  per  cent,  of  all  women  during  pregnancy,  and  in 
one-third  of  women  during  labor.  What  is  still  more  remarkable, 
during  the  last  month  of  pregnancy  the  urine  of  nearly  all  women  con- 
tains hyaline  casts  and  leucocytes.  This  change  in  the  secretion  of  the 
healthy  kidney  is  known  as  the  kidney  of  pregnancy,  and  is  doubtless 
chiefly  due  to  the  increased  abdominal  pressure  ;  but  maybe  there  also 
is  a  toxic  agent  at  work.  The  kidney  of  pregnancy  is  commonly  found 
in  the  second  half  of  pregnancy  and  particularly  among  primiparae.     It 


SYSTEMIC   DISTURBANCES   DUE   TO   PREGNANCY.  335 

is  accompanied  by  some  oedema  of  the  lower  extremities  ;  but  other- 
wise it  does  not  give  rise  to  symptoms  ;  and,  as  a  rule,  the  urine 
becomes  normal  again  shortly  after  delivery. 

In  other  cases  it  is  only  the  precursor  of  acute  or  chronic  nephritis 
and  may  lead  to  eclampsia.  The  transition  from  a  normal  condition  to 
a  most  dangerous  one  is  then  almost  insensible,  so  far  as  the  kidneys 
are  concerned,  and,  as  we  have  said  above,  the  secretion  should  be 
carefully  watched,  especially  towards  the  end  of  pregnancy. 

If  women  who  are  suffering  from  chronic  nephritis  become  preg- 
nant, the  kidney  disease  is  aggravated,  and  interruption  of  pregnancy 
is  therefore  often  indicated.  The  diagnosis  is  based  upon  the  history 
of  the  case  and  on  the  presence  of  fatty,  granular,  or  waxy  casts. 

Acute  nephritis  may  also  develop,  and  is  characterized  by  the  pres- 
ence of  numerous  red  blood-corpuscles  in  the  urine  and  a  rise  in 
temperature.  ' 

All  kinds  of  inflammations  of  the  kidneys  are  apt  to  be  accompa- 
nied by  hemorrhages.  Most  common  is  the  loosening  of  the  nor- 
mally inserted  placenta,  which  frequently  becomes  the  cause  of  the 
death  of  the  foetus  and  may  also  endanger  the  life  of  the  mother. 
Frequently  the  placenta  is  found  to  contain  white  infarcts.  Small 
infarcts  are  quite  common  in  the  placentge  of  healthy  women,  but  large 
ones  are  mostly  allied  with  albuminuria.  These  infarcts  are  formed  by 
endarteritis  of  the  villi  of  the  chorion.^ 

In  other  cases  bleeding  from  the  intestine,  nose,  and  mouth  has 
been  observed. 

A  particular  form  of  inflammation  of  the  eye — retinitis  alhumi- 
nurica — has  also  been  described. 

Treatment. — The  strictly  normal  kidney  of  pregnancy  does  not  call 
for  any  therapeutic  interference  ;  but  as  soon  as  the  limit  seems  to  be 
passed,  the  treatment  described  for  the  premonitory  stage  of  eclampsia 
is  indicated  ;  and  if  the  condition  assumes  a  serious  aspect  pregnancy 
should  be  brought  to  an  end. 

§  22.  Fever  of  Pregnancy, — Some  authors  have  described  a  fever 
for  which  they  could  find  no  other  reason  except  pregnancy  itself. 
It  has  a  remittent  type,  becoming  worse  towards  evening.  The 
patient  becomes  hot,  restless,  and  cannot  sleep.  She  loses  flesh. 
Sometimes  she  has  an  intolerable  sensation  of  heat  in  the  genitals. 
The  disturbance  may  begin  early  and  last  during  a  large  part  of  preg- 
nancy and  even  till  its  end. 

Cold  applications  of  plain  water  or  a  lead-and-opium  wash  may 
be  tried  and  antipyretics  given  internally. 

§  23.  Icterus. — A  pregnant  woman  may  develop  a  common  catar- 
rhal icterus  which  runs  its  usual  course  and  is  treated  with  the  same 

^  Withridge  Williams,  Johns  Hopkins  Hospital  Reports,  vol.  ix. 


336  ABNORMAL   PREGNANCY. 

remedies  as  in  the  unimpregnated.  But  there  is  a  tendency  during 
pregnancy  to  develop  a  mahgnant  form  of  jaundice,  called  icterus 
gravis,  which  is  an  exceedingly  dangerous  disease,  in  most  cases  con- 
nected with  yellow  atrophy  of  the  liver.  Whether  it  is  due  only  to 
pressure  on  the  ducts  leading  the  bile  from  the  liver  and  gall-bladder 
to  the  intestine,  or  there  comes  an  infectious  element  into  play,  is  not 
known. 

Frequently  the  child  is  dead  and  still  oftener  it  is  born  icteric. 

In  view  of  the  comparative  frequency  with  which  the  malignant 
form  of  jaundice  appears  in  pregnant  women,  it  is  wise  for  the  phy- 
sician to  be  reserved  in  his  prognosis  in  any  case  of  icterus  occurring 
during  pregnancy. 

§  24.  Progressive  Pernicious  Anaemia. — We  know  that  normally 
the  blood  of  pregnant  women  becomes  more  watery  and  contains  less 
haemoglobin  than  that  of  the  unimpregnated.  We  have  also  seen 
that  oedematous  swelling,  especially  of  the  lower  extremities,  is  quite 
common  and  does  not  forebode  any  ill.  But  sometimes  the  limits 
of  the  normal  are  overstepped.  Pregnant  women  are  more  liable 
than  others  to  fall  victims  to  that  mysterious  and  dread  disease  known 
as  pernicious  anaemia.  It  appears  commonly  in  the  second  half  of 
pregnancy.  It  is  likely  to  cause  abortion  or  premature  labor,  and  is 
nearly  always  fatal.  When  the  diagnosis  is  made,  which  is  based  upon 
the  undisturbed  nutrition  combined  with  pallor,  great  weakness,  ten- 
dency to  hemorrhage,  and  great  destruction  of  the  red  blood-corpuscles, 
an  attempt  should  be  made  to  arrest  the  disease  by  means  of  the 
extract  of  red  bone  marrow  in  large  doses,  a  tablespoonful  three  or 
four  times  a  day,  together  with  a  rich  albuminoid  diet  and  pure  strong 
wine.  But  if  a  decided  improvement  does  not  soon  begin,  pregnancy 
should  be  interrupted,  and  the  same  treatment  continued ;  or  other 
remedies  substituted,  especially  arsenic,  and  if  there  is  no  hemorrhage, 
chalybeates.  But  even  after  the  uterus  has  been  emptied  the  prog- 
nosis is  very  doubtful. 

§  25.  Leucocythaemia,  or  Leukaemia. — In  normal  pregnancy  the 
number  of  leucocytes  is  increased,  but  in  rare  cases  a  true  leuco- 
cythaemia develops.  Then  there  is  an  enormous  increase  in  colorless 
blood-corpuscles,  and  there  appear  large  mononuclear  cells  without 
haemoglobin  and  nucleated  red  blood-corpuscles.  The  disease  does  not 
pass  to  the  foetus  ;  nor  does  it,  if  congenital  in  the  fcetus,  implicate  the 
mother,  showing  that  the  partition  between  the  maternal  and  fetal 
organisms  in  the  placenta  is  impermeable  to  colorless  blood-corpuscles. 
The  chronic  form  has  less  influence  on  pregnancy,  although  it  some- 
times leads  to  miscarriage  ;  but  it  appears  also  in  an  acute  form, 
which  ends  in  a  few  weeks,  and  usually  leads  to  the  death  of  the 
fffitus. 


SYSTEMIC    DISTURBANCES   DUE   TO    PREGNANCY.  337 

If  the  mother's  condition  becomes  aggravated  through  pregnancy, 
it  is  proper  to  seek  to  better  it  by  the  artificial  termination  of  the 
gestation. 

§  26.  Pemphigus. — A  small  number  of  cases  have  been  reported 
in  which  a  vesicular  eruption  took  place  during  pregnancy,  disap- 
peared after  childbirth,  and  had  a  tendency  to  reappear  in  each  follow- 
ing pregnancy.  The  eruption  begins,  as  a  rule,  on  the  extremities, 
from  which  it  extends  to  the  trunk,  but  it  hardly  ever  invades  the 
head.  It  consists  of  red  spots  upon  which  appear  vesicles  varying 
in  size  from  that  of  a  pea  to  that  of  a  Avalnut.  They  are  grouped 
together.  Their  contents,  at  first  serous,  become  mucopurulent. 
These  blebs  dry  up  and  form  a  thick  scab,  after  the  fall  of  which 
the  skin  for  some  time  presents  a  dark-blue  color.  The  eruption  is 
accompanied  by  a  burning  and  itching  sensation  which  prevents  the 
patient  from  sleeping,  causes  fever,  loss  of  flesh,  and  general  debility. 

As  treatment,  alkaline  washes  and  internal  tonics,  such  as  iron, 
arsenic,  strychnine,  cod-liver  oil,  quinine,  etc.,  are  recommended. 

§  27.  Impetig-o  herpetiformis  is  a  very  serious  disease,  since  of 
five  patients  described  by  Hebra  four  died.  During  the  latter  months 
of  pregnancy  there  appears  at  the  groin,  at  the  umbilicus,  on  the 
breasts,  in  the  armpits,  and  later  in  many  other  places,  an  eruption 
consisting  of  small  pustules  of  the  size  of  pin-heads,  closely  grouped 
together,  and  filled  with  a  thick  greenish-yellow  fluid.  These  pustules 
dry  up  and  form  a  thick  brown  scab,  around  which  spring  up  new 
pustules  whose  scabs  become  merged  in  the  first  one.  Gradually  the 
circles  join  one  another  until,  finally,  the  whole  body  is  covered  with 
the  eruption.  The  patient  has  a  continuous  or  remittent  fever,  the 
tongue  becomes  dry,  and,  as  a  rule,  the  issue  is  fatal. 

Treatment. — It  is  proper  to  prescribe  arsenic  internally  and  derma- 
tol  and  similar  powders  externally. 

§  28.  Mastitis. — The  development  of  the  mammary  glands  during 
pregnancy  sometimes  leads  to  an  inflammation  and  formation  of  an 
abscess.  In  some  cases  the  starting-point  is  an  eczema  of  the  areola. 
The  patient  should  lie  in  bed.  Garrigues's  waist  (Fig.  239)  should  be 
applied,  and  outside  of  that  an  ice-bag.  If  an  abscess  forms,  it  must 
be  opened  and  drained. 

§  29.  Eczema  of  the  Areola. — This  is  not  very  rare  and  causes 
annoyance  by  its  itching,  and  may,  as  we  have  said,  lead  to  mastitis. 
The  affected  part  should  be  covered  with  compresses  dipped  in  Burow's 
solution  of  acetate  of  aluminum,  renewed  when  it  gets  dry,  or  rubbed 
with  ointment  of  lead. 

The  same  unguent  is  also  smeared  on  a  piece  of  muslin,  with  which 
the  affected  part  is  covered.  Outside  is  placed  a  piece  of  gutta-percha 
tissue  and  then  the  waist.   The  ointment  is  used  morning  and  evening. 

22 


338  ABNORMAL   PREGNANCY. 


CHAPTER   VIII. 
COMPLICATION  WITH   ACUTE    INFECTIOUS   DISEASES. 

§  1.  Gonorrhoea. — Modern  researches  have  taught  us  how  serious 
an  affection  a  gonorrhoea  is,  and  how  great  an  influence  it  exercises 
on  propagation.  Quite  frequently  it  renders  both  man  and  woman 
sterile,  but  for  the  female  sex  it  is  much  more  dangerous,  often  invad- 
ing the  internal  genitals  and  causing  endometritis,  salpingitis,  oophor- 
itis, and  more  or  less  wide-spread  peritonitis,  affections  that  may  end 
fatally  or  leave  the  patient  an  invalid  or  necessitate  dangerous  and 
mutilating  operations  that  often  lead  to  other  irremediable  sufferings. 
Even  many  years  after  having  been  infected  a  man  can  produce  such 
an  effect  by  so-called  latent  gonorrhoea. 

Besides  thus  opposing  a  barrier  to  conception,  gonorrhoea,  if 
impregnation  takes  place,  may  have  a  baneful  influence  on  gravidity, 
labor,  and  the  puerperal  state. 

The  gonococci  work  their  way  into  the  mucous  membrane  and 
submucous  tissue  of  the  vagina,  and  cause  the  formation  of  small 
elevations  varying  in  size  from  that  of  a  millet-seed  to  that  of  a  lentil 
— so-called  granular  colpitis. 

Not  infrequently  papillomas — so-called  vegetations,  or  venereal 
warts — are  formed,  which  may  fill  the  vagina  and  oppose  a  serious 
hinderance  to  the  passage  of  the  child.  There  is  also  great  danger 
of  the  child  acquiring  ophthalmia  and  becoming  blind.  During  preg- 
nancy the  gonorrhoea  is  not  very  likely  to  affect  the  deeper  parts, 
although  it  may  attack  the  ovum  and  cause  its  rupture.  It  may  also 
lead  to  premature  detachment  of  the  placenta,  in  which  cases  gono- 
cocci have  been  found  in  the  decidua.  After  delivery  it  may  give 
rise  to  wide-spread  purulent  pelvic  inflammation,  which  may  end 
fatally. 

In  regard  to  treatment,  the  reader  is  referred  to  what  we  have 
said  above  in  speaking  of  colpitis  and  vegetations  (pp.  284,  289). 

§  2.  Other  Acute  Infectious  Diseases. — Formerly  people  believed 
that  the  pregnant  state  gave  immunity  against  most  acute  diseases,  but 
growing  experience  has  shown  that  this  is  not  so.  If  typhoid  fever, 
scarlet  fever,  and  measles  are  rather  rare,  cholera  and  smallpox  seem 
to  be  more  frequent  than  out  of  pregnancy,  and  nearly  all  acute  dis- 
eases have  a  bad  influence  on  both  the  mother  and  the  foetus.  The 
maternal  mortality  is  greater  and  abortion  very  common.  These  dis- 
eases are  apt  to  take  on  a  hemorrhagic  form,  and  in  cholera  a  hemor- 
rhagic endometritis  often  develops  in  both  pregnant  and  unimpregnated 
women.  In  smallpox  the  maternal  mortality  reaches  sixty-seven  per 
cent,  and  in  typhoid  fever  abortion  occurs  in  sixty-three  per  cent.     The 


COMPLICATION   WITH    ACUTE   INFECTIOUS   DISEASES.  339 

loss  of  blood  weakens  the  mother  and  deprives  her  of  some  of  her 
power  of  resistance. 

The  great  fetal  mortality  may  be  due  to  different  causes.  It  may 
be  brought  about  by  the  hyperpyrexia, — that  is  to  say,  the  accumula- 
tion of  heat.  It  has  been  noticed  that  for  every  fifth  of  a  degree  of 
Fahrenheit's  thermometer  the  pulse  frequency  increases  by  three  beats 
per  minute.  Or  death  may  be  caused  by  asphyxia.  The  pleura  and 
other  membranes  of  the  foetus  show  numerous  petechiae,  minute  ex- 
travasations of  blood  due  to  attempts  at  breathing.  It'has  also  been 
found  by  experiments  on  animals  that  when  the  mother  is  near  suffo- 
cation the  exchange  of  gas  in  the  placenta  goes  in  the  opposite  direc- 
tion to  the  normal,  the  foetus  giving  off  oxygen  to  the  mother,  which 
is  proved  by  the  blood  in  the  umbilical  vein  being  darker  than  that  of 
the  umbilical  arteries. 

Thirdly,  the  disease  may  be  directly  transferred  from  the  mother 
to  the  child.  While  under  normal  circumstances  not  a  blood-corpuscle 
or  any  other  solid  substance  can  pass  through  the  barrier  of  the 
placenta,  the  disease  itself  may  break  down  its  integrity,  and  germs 
pass  from  the  mother  to  the  child.  Thus  the  bacillus  of  typhoid  fever, 
the  spirillus  of  recurrent  fever,  the  bacillus  of  erysipelas,  the  comma 
bacillus  of  Asiatic  cholera,  the  pneumococcus,  streptococci,  staphy- 
lococci, and  bacillus  coli  communis  have  all  been  found  in  the  foetus. 
In  scarlet  fever  the  foetus  seems  to  be  affected  at  the  same  time  as  the 
mother.  It  may  be  born  with  the  rash  or  in  the  stage  of  desquama- 
tion. The  same  is  the  case  with  measles.  In  smallpox  the  child  may 
be  born  with  pustules  or  cicatrices.  In  malaria  the  Plasmodium  has 
not  been  found  in  the  foetus,  but  the  child  has  been  born  with  a 
swollen  spleen.  When  the  mother  has  influenza,  the  child  may  be 
born  with  it,  as  evinced  by  sneezing,  rapid  respiration,  high  tempera- 
ture, and  frequent  pulse.  The  anthrax  bacillus  has  not  been  found  in 
the  foetus,  but  the  child  is  taken  sick  a  few  days  after  its  birth,  show- 
ing that  infection  probably  takes  place  during  birth,  especially  during 
the  detachment  of  the  placenta. 

Perhaps  the  foetus  may  also  be  killed  by  absorbing  toxins  from 
the  mother. 

Sometimes  the  death  of  the  foetus  may  be  caused  secondarily  by 
premature  uterine  contractions  excited  by  the  overheated  blood. 

In  typhoid  fever,  cholera,  and  smallpox  hemorrhage  often  takes 
place  in  the  decidua. 

In  cholera  there  is  a  sudden  diminution  in  the  liquor  amnii.  It 
is  very  dangerous,  not  only  during  pregnancy,  but  also  during  the 
first  days  of  the  puerperium. 

Smallpox  may  affect  one  twin  while  the  other  escapes,  and,  what 
is  still  more  curious,  the  child  may  be  born  with  it  although  the  dis- 


340  ABNORMAL   PREGNANCY. 

ease  did  not  affect  the  mother.  If  the  mother  had  it  during  gestation, 
the  child  is  refractory  to  vaccination.  If  the  mother  was  vaccinated 
during  pregnancy,  vaccination  sometimes  takes  in  the  child  and  some- 
times not. 

Pneumonia  and  pleurisy  are  exceedingly  dangerous  complications 
of  pregnancy.  If  labor  has  not  begun,  everything  should  be  done  to 
postpone  it.  The  induction  of  premature  labor  is  contraindicated, 
because  labor  interferes  with  respiration  and  throws  extra  work  on 
the  heart.  If,  on  the  other  hand,  labor  has  begun,  the  sooner  the 
patient  can  get  through  w^th  it  the  better,  and  the  accoucheur  should, 
therefore,  use  every  known  means  of  expediting  the  process,  such  as 
dilatation  of  the  cervix,  version  and  extraction,  or  forceps  delivery. 

Erysipelas  is  one  of  the  most  dangerous  complications  of  preg- 
nancy, the  streptococcus  causing  this  disease  and  the  worst  form  of 
puerperal  infection  being  identical. 

Influenza  interferes  with  conception  and  is  a  frequent  cause  of 
abortion.  It  was  noted  that  nine  or  ten  months  after  a  large  epi- 
demic in  Switzerland  there  was  a  great  diminution  in  childbirth,  so 
that  in  1890  there  were  5287  less  confinements  than  the  average  of 
the  four  preceding  years. 

Hydrophobia  has  been  observed  in  few  pregnant  women.  The 
children  remained  healthy. 

Injuries  are  common,  and  if  they  lead  to  septiccemia  the  foetus  nearly 
always  dies. 

Smallpox  and  erysipelas  are  so  exceedingly  dangerous  and  so 
easily  carried  from  one  patient  to  another  that,  whenever  feasible, 
doctors  and  midwives  who  have  such  a  case  on  hand  should  abstain 
from  going  to  a  pregnant  or  parturient  woman.  If  they  are  obliged 
to  do  so,  they  should  change  all  their  clothes,  take  an  entire  bath 
with  corrosive  sublimate,  and  pay  extra  attention  to  the  disinfection 
of  their  hands. 


CHAPTER   IX. 
COMPLICATION   WITH    CHRONIC    DISEASES. 

§  1.  Syphilis. — Among  chronic  diseases  syphilis  has  the  greatest 
influence  on  pregnancy.  If  the  father  has  syphilis  in  the  primary  or 
secondary  stage,  both  the  mother  and  the  foetus  become  infected. 

If  the  mother  at  the  time  of  conception  has  syphilis  in  these  early 
stages,  she  communicates  it  also  to  the  foetus.  If  she  is  healthy  when 
she  conceives  and  becomes  infected  later,  the  result  in  regard  to  the 
child  differs.  The  nearer  conception  the  infection  occurs,  the  more 
likely  is  the  foetus  to  get  the  disease,  but  if  the  infection  does  not  take 


COMPLICATION   WITH    CHRONIC   DISEASES.  341 

place  before  the  last  three  months  of  pregnancy  the  foetus  nearly 
always  escapes  contamination. 

A  woman  may  live  with  a  syphilitic  man  for  years  without  being 
infected,  but  Avhen  she  becomes  pregnant  by  the  same  man,  she  may 
become  infected  through  the  foetus,  by  what  the  French  call  choc  de 
retour. 

When  the  man  is  in  the  tertiary  stage  of  syphilis,  both  mother  and 
foetus  may  escape  infection.  If  the  disease  is  old  in  both  parents,  the 
child  may  be  born  apparently  healthy,  but  syphilis  is  latent  in  it  and 
may  break  out  after  many  years. 

The  same  may  be  the  case  if  the  mother,  during  her  pregnancy, 
undergoes  thorough  mercurial  treatment. 

Fig.  267. 


Syphilitic  villus  of  the  chorion.     (Friinkel.) 

Syphilis  in  the  mother  exercises  its  influence  on  the  foetus  longer 
than  that  of  the  father ;  but,  as  a  rule,  the  parental  influence  ceases 
after  a  lapse  of  from  four  to  six  years.  Exceptionally  it  may  continue 
ten  years  or  more,  one  abortion  following  the  other. 

Often  the  syphilitic  foetus  is  expelled  in  the  earlier  months  of  preg- 
nancy. If  development  goes  on  longer,  the  foetus  is  born  in  a  macer- 
ated condition.  The  time  of  the  occurrence  of  abortion  is  com- 
mensurate with  the  time  elapsed  since  the  parents  were  infected. 
Thus,  in  successive  pregnancies  abortions  are  followed  by  premature 
labor,  until  finally  sometimes  a  viable  child  is  born. 


342 


ABNORMAL    PREGNANCY. 


The  cause  of  the  death  of  the  foetus  and  the  miscarriage  is  found 
in  the  placenta,  which  is  unusually  large  and  heavy.  In  the  interior 
of  the  villi  of  the  chorion  numerous  round  and  spindle-shaped  cells 
are  produced,  which  compress  and  finally  obliterate  the  blood-vessels. 
The  epithelium  of  the  vilh  undergoes  also  a  cell  proliferation,  and  the 
whole  villus  becomes  swollen.     (Figs.  267,  268). 

The  maternal  part  of  the  placenta  becomes  the  seat  of  a  gummous 
endometritis,  forming  nodules  of  connective  tissue.  The  liver  and  the 
spleen  are  swollen  and  may  weigh  three  times  as  much  as  normal.  The 
junctions  of  the  diaphyses  and  the  epiphyses  undergo  great  changes, 
which  will  be  described  later.     (See  Diseases  of  the  New-Born.) 

Fig.  268. 


Villi  from  the  line  of  demarcation  between  healthy  and  diseased  placental  tissue.  (Frankel.) 
a,  swollen  villus  filled  with  granulation  cells ;  6,  slender,  almost  healthy  villus  ;  c,  transition  from 
healthy  to  diseased  villus. 

As  soon  as  a  pregnant  woman  affected  with  syphilis  comes  under 
observation,  she  ought  to  be  treated  with  mercury.  This  drug  is  not 
only  borne  well  by  mother  and  child,  but  the  number  of  miscarriages 
and  premature  labors  is  much  diminished  under  its  use. 

If  the  mother  aborts  or  gives  birth  to  a  macerated  child,  she  ought 
to  undergo  mercurial  treatment  before  a  new  conception  takes  place, 
and  probably  the  husband  will  need  the  same  cure. 

§  2.  Tuberculosis. — Pregnancy  has  a  bad  influence  on  tuberculous 
patients.  The  ravages  of  the  disease  continue,  and  the  weakening 
influence  of  the  puerpery  is  still  more  deleterious.  Sometimes  the 
patients  die,  and  then,  as  a  rule,  when  the  fatal  issue  approaches,  the 
child  is  born  before  the  normal  term.  Otherwise  the  disease  rarely 
causes  abortion  or  premature  labor.  Fortunately,  tuberculous  patients 
are  less  apt  to  conceive.  Their  children  are  mostly  small  and  weak  ; 
but  exceptions  are  not  rare  when  a  tuberculous  mother  gives  birth  to 
a  plump  child. 


COMPLICATION    WITH    CHRONIC    DISEASES.  343 

A  direct  transfer  of  tubercle  bacilli  rarely  takes  place.  If  it  does, 
the  epithelial  cover  of  the  villi  of  the  chorion  and  the  interior  of  the 
villi  are  found  diseased.  Blood-vessels  become  obliterated,  caseous 
foci  are  formed,  and  the  fetal  blood  swarms  with  bacilli.  The  supra- 
renal capsules  have  also  been  found  in  a  caseous  condition. 

If  the  direct  transition  of  bacilli  is  rare,  there  can  be  no  doubt 
about  the  disease  being  frequently  inherited  from  the  mother.  The 
same  applies  to  the  father,  in  which  case  we  must  suppose  a  so  far 
inexplicable  infection  through  the  semen.  In  both  cases  the  disease 
may  not  appear  for  many  years.  Perhaps  it  then  is  due  to  direct 
infection  later  in  life. 

A  tuberculous  mother  ought  not  to  nurse  her  child. 

§  3.  Heart  Disease. — In  itself  a  dangerous  condition,  valvular 
heart  disease  becomes  much  more  so  during  pregnancy,  when  even 
under  normal  circumstances  the  heart  has  to  perform  increased  work. 
If  the  valvular  disease  is  perfectly  compensated,  pregnancy  may  have  a 
smooth  course  ;  but  if  the  compensation  is  imperfect,  the  prognosis  is 
doubtful.  Dyspnoea,  cyanosis,  anasarca,  ascites,  albuminuria,  hydro- 
thorax,  and  pulmonary  oedema  may  develop  ;  an  embolus  may  cause 
apoplexy  or  a  fibrinous  clot  form  in  the  heart,  or  fresh  endocarditis 
may  increase  the  obstruction  to  circulation.  Sudden  death  may  occur 
either  during  pregnancy,  during  labor,  or  in  the  puerperium  through 
paralysis  of  the  heart.  In  pregnancy  a  fatal  exit  is  not  common,  but 
the  exertion  of  labor  is  particularly  dangerous,  and  there  is  still  a  con- 
siderable mortality  during  the  puerpery. 

The  moment  following  the  expulsion  of  the  child  is  particularly 
dangerous,  which  probably  is  due  to  the  diminished  abdominal  pres- 
sure, when  all  the  large  abdominal  vessels  become  overfilled  with 
blood,  and  there  is  a  temporary  lack  of  blood  in  the  heart,  which  may 
arrest  its  motion. 

Heart  disease  often  causes  abortion  or  premature  labor. 

Treatment. — The  pregnant  woman  suffering  from  heart  disease 
should  be  spared  all  physical  exertion  and  mental  emotion.  If  her 
condition  becomes  dangerous,  it  may  be  necessary  to  perform  artificial 
abortion.  Induction  of  premature  labor  is  less  often  indicated.  The 
membranes  should  be  ruptured  early,  since  the  escape  of  liquor  amnii 
already  gives  some  relief  from  the  dyspnoea.  During  labor  the  patient 
will,  as  a  rule,  be  unable  to  occupy  the  common  postures  on  the  back 
or  the  left  side,  and  must  sit  up  in  order  to  breathe.  Labor  should  be 
abbreviated  as  much  as  possible  by  artificial  dilatation  of  the  cervix, 
the  high  forceps  operation,  or  version.  For  anaesthesia  ether  should 
be  used,  which  stimulates  the  heart,  while  chloroform  is  particu- 
larly dangerous.  The  hypodermic  administration  of  digitalis,  stro- 
phanthus,  strychnine,  and  nitroglycerin  may  prove  highly  serviceable. 


344  ABNORMAL   PREGNANCY. 

It  is  well  to  have  in  readiness  a  sand-bag  weighing  eight  or  nine  pounds 
and  to  place  it  on  the  abdomen  Lhe  moment  the  child  is  expelled  or 
extracted. 

Endocarditis  may  develop  during  pregnancy  in  otherwise  healthy 
women,  and  is  easily  overlooked,  unless  an  apoplectic  attack  leads  the 
attention  to  the  heart. 

jExophfhalmic  goitre  gets  worse  during  pregnancy,  and  can  become 
the  cause  of  abortion. 

§  4.  Haemophilia  is,  fortunately,  a  rare  disease,  and  those  who  are 
affected  by  it  are  likely  to  succumb  to  hemorrhages  following  small 
injuries  before  reaching  the  childbearing  age.  If  a  woman  suffering 
from  this  disease  becomes  pregnant,  there  is  considerable  danger  of 
serious  hemorrhage  occurring  during  pregnancy  or  labor.  Hemor- 
rhage may  take  place  in  the  decidua,  leading  to  abortion,  and  during 
any  of  the  stages  of  labor,  especially  the  third,  or  immediately  after 
the  expulsion  of  the  placenta,  the  patient  may  bleed  to  death. 

Knowing  the  disposition  of  the  patient  to  hemorrhage,  the  ac- 
coucheur must  be  prepared  to  combat  it  in  every  way,  with  tam- 
ponade, styptics,  ligature,  faradization,  ice,  hot  water,  or  thermocau- 
terization. 

§  5.  Hernia. — Hernia  being  so  common  a  condition,  it  is  a  frequent 
complication  of  pregnancy  and  childbirth,  but,  as  a  rule,  it  does  not  give 
much  trouble.  Old  inguinal  and  femoral  herniee  may  even  disap- 
pear during  pregnancy,  the  intestine  being  pushed  up  by  the  growing 
uterus  and  pulled  out  of  the  inguinal  or  crural  canal.  On  the  other 
hand,  an  umbilical  hernia,  by  the  distention  of  the  linea  alba,  espe- 
cially among  pluriparge,  is  apt  to  make  its  first  appearance  or  get 
worse  during  pregnancy.  In  rare  cases  the  intestine  may  be  com- 
pressed in  Douglas's  pouch.  The  writer  has  seen  an  inguinal  hernia 
form  in  a  first  pregnancy  in  a  woman  who  had  never  had  one,  and  in 
whom  it  disappeared  again  shortly  after  the  birth  of  the  child.  It  is 
easy  to  understand  the  mechanism  of  such  an  accident.  By  the  growth 
of  the  uterus  the  abdominal  wall  becomes  distended  and  the  inguinal 
canal  enlarged,  so  as  to  facilitate  the  passage  of  the  intestine,  and 
during  involution  the  canal  becomes  again  narrow  enough  to  resist  the 
escape  of  the  gut. 

An  umbilical  hernia  should  be  kept  back  with  a  pad  and  spring, 
but  trusses  cannot  be  applied  to  inguinal  or  femoral  hernias.  In  the 
case  referred  to  above  the  hernia  caused  pain,  and  was  successfully  kept 
back  with  a  pad  and  elastic  narrow  silk  strap  surrounding  the  pelvis, 
made  by  the  Pomeroy  Truss  Company,  on  Union  Square,  New  York. 

If  a  hernia  becomes  incarcerated,  taxis  should  be  tried,  and  if 
successful,  some  such  supporter  should  be  used  to  keep  the  intestine 
in.     If  it  is  not  possible  to  replace  it,  herniotomy  must  be  performed. 


DEATH    OF  THE   MOTHER    DURING    PREGNANCY.  345 

Induction  of  premature  labor  has  also  given  a  good  result.  During 
labor  the  hernia  should  be  kept  back  manuallj%  and  if  there  is  any 
pressure  on  it  delivery  should  be  expedited  with  the  forceps. 


CHAPTER   X. 

DEATH    OF   THE   MOTHER   DURING   PREGNANCY. 

The  laws  of  most  countries  prescribe  that  if  a  pregnant  woman 
dies,  and  the  foetus  is  alive  and  at  a  period  of  development  at  which 
it  is  viable,  it  shall  be  the  duty  of  the  physician  to  perform  Caesarean 
section  on  the  body, — that  is  to  say,  cut  through  the  abdominal  and 
uterine  walls  and  remove  the  child.  This  was  already  a  law  with  the 
old  pagan  Ptomans,  and  the  Roman  Catholic  Church,  desiring  to  give 
the  child  the  benefit  of  the  baptismal  rite,  inculcated  the  same.  Nu- 
merous operations  of  this  kind  have  been  performed,  but  the  outlook  for 
delivering  a  living  child  and  for  its  remaining  alive  is  poor  indeed.  Puech 
found  that  in  331  operations,  101  children  showed  signs  of  life  when 
born,  but  only  43  continued  to  live.  The  foetus  dies  of  asphyxia  very 
soon  after  the  mother.  To  have  any  chance  of  success,  the  opera- 
tion must  be  performed  within  a  few  minutes  after  the  death  of  the 
mother.  Ten  minutes  later  there  is  very  little  hope  of  saving  the  child, 
although  there  is  a  case  on  record  in  which  the  foetus  was  extracted 
twenty-three  minutes  after  the  death  of  the  mother ;  it  was  deeply 
asphyxiated,  but  survived.  The  chances  are  best  when  the  mother  is 
suddenly  killed  by  some  injury,  but  how  rarely  will  a  physician  then  be 
present  and  be  prepared  to  operate  !  If  she  dies  of  some  protracted 
disease,  the  chances  are  that  the  foetus  is  nearly  dead  when  she  dies. 
He  must  watch  her  heart  with  the  stethoscope,  and  when  it  stops 
pulsating  ascertain  that  the  fetal  heart  still  beats.  If  he  is  precipi- 
tate in  his  action,  he  may  share  the  fate  of  that  practitioner  who 
thought  he  was  operating  on  a  corpse,  but  the  pain  of  the  incision 
revived  the  mother,  and  the  operator  fled  in  dismay. 

Deliberately  to  operate  while  the  mother  is  dying,  as  has  been 
recommended,  seems  to  the  writer  utterly  revolting  and  barbarous, 
unless  the  mother  herself  wishes  it.  The  operation  must,  of  course, 
be  performed  without  any  kind  of  general  anaesthesia,  which  would 
hasten  death. 

If  the  woman  is  really  dead,  the  operation  is  simple  enough,  and 
might  in  the  absence  of  the  usual  instruments  be  performed  with  a 
razor  or  any  sufficiently  sharp  knife. 

A  living  child  may  even  be  born  by  the  natural  way  after  the 
death  of  the  mother.     Somatic  death  is  a  protracted  process,  and  it 


346 


ABNORMAL   PREGNANCY. 


is  not  incomprehensible  that  the  uterus  may  contract  ancl  expel  the 
child  after  the  mother's  heart  has  ceased  beating. 

If  the  mother  dies  during  labor,  it  may  sometimes  be  possible  for 
the  accoucheur  to  express  or  extract  the  child  per  vias  naturales. 


CHAPTER   XL 
DISEASES    OF   THE    OVUM. 

§  1.  Amniotic  Bands. — Not  infrequently  solid  or  hollow  bands 
are  found  extending  from  the  skin  of  the  fcetus  to  the  inside  of  the 
amniotic  cavity  (Fig.  269),  or  between  different  parts  of  the  foetus 

(Fig.  270).     These  strings  may 
Fig.  269.  cause  intra-uterine  amputation 

of  limbs  (Fig.  271),  the  cut-off 
parts  sometimes  being  found  in 
the  liquor  amnii.  The  bands 
may  also  prevent  a  whole  limb 
from  being  developed,  or  they 
may  compress  the  cord  and 
thus  cause  the  death  of  the 
foetus,  or  the  adhesion  between 
the  ovum  and  the  fcetus  may  be 
placed  so  as  to  prevent  the  for- 
mation of  the  cord.  When  a 
tubular  band  has  been  recently 
torn  off  from  the  foetus,  the 
corresponding  part,  usually  the  back  of  the  head,  will  show  a  defect 
in  the  skin,  like  a  wound. 

These  bands  are  doubtless  due  to  a  kind  of  arrest  of  development, 
the  amnion  not  separating  all  over  from  the  foetus  by  intervening  liquor 
amnii,  but  remaining  in  contact  in  some  places  with  the  foetus.  Thus 
broader  adhesions  would  be  formed,  but  when  the  liquor  amnii  in- 
creases in  amount  these  adhesions  are  drawn  out  in  the  shape  of 
strings  or  tubes. 

§  2.  Hydramnion,  or  Hydramnios. — Hydramnion  is  a  dropsy  of 
the  amnion,  too  large  an  amount  of  liquor  amnii.  It  is  not  possible 
to  define  the  limit  where  hydramnios  begins.  The  normal  amount 
of  amniotic  fluid  is  two  or  three  pounds,  but  we  hardly  call  the  excess 
hydramnion  unless  it  gives  rise  to  some  discomfort  or  danger. 

Etiology. — Hydramnion  is  much  more  common  among  pluriparse 
than  among  primiparse.  It  is  often  combined  with  twin  pregnancy, 
and  quite  frequently  the  fcetus  is  malformed  or  diseased.     In  a  general 


Amniotic  bands  extending  from  lie uis  lo  amnion. 
(Knard.) 


DISEASES    OF    THE    OVUM. 


347 


way  we  may  say  that  anything  that  increases  the  secretion  or  interferes 
with  the  resorption  of  the  hquor  amnii  may  be  a  cause  of  hydram- 
nion.     The  cause  is  by  far  more  commonly  situated  in  the  ovum  or 

Fig.  270. 


Amniotic  bands  encircling  legs  of  four-months-old  foetus.    (Ahlfeld.) 


Fig.  271. 


the  foetus  than  in  the  mother.  In  speaking  of  the  ovum  at  term  (p.  66) 
we  have  said  that  the  amnion  has  neither  nerves  nor  blood-vessels, 
but  at  an  earlier  stage  arteries,  veins,  and  capillaries,  the  so-called 
vasa  propria^  are  found,  which  later  become  solid  fibrous  strings,  and 
are  normally  closed  two  months  before  the  end  of  pregnancy.  If  these 
vessels  abnormally  remain  open,  a  transudation  of  serum  takes  place 
through  their  walls,  giving  rise  to  hydram- 
nion.  In  other  cases  the  amnion  is  found 
inflamed,  thickened,  and  its  epithelium 
in  a  state  of  cell  proliferation.  Some- 
times a  stenosis  has  been  found  in  the 
umbilical  vein  or  a  cirrhotic  liver  of 
syphilitic  origin  or  valvular  disease  in 
the  fetal  heart  or  stenosis  of  the  ductus 
Botalli,  all  of  which  would  cause  a  stasis 
of  blood  and  transudation  of  serum. 

Very  often  fetal  anomalies  are  found, 
such  as  hydrorrhachis,  exstrophy  of  the 
bladder,  hemicephalus,  cleft  palate,  hare- 
lip, adhesions  of  the  amnion  to  the  sur- 
face of  the  foetus  or  to  inner  organs  in 
still  open  cavities,  where  blood-vessels 
may  lie   freely  exposed  in  a  condition 


Intra-uterinc  amputation  of  fingers. 
(Olshausen-Vcit.) 


favoring  transudation  of  serum, 
seat  of  neevi. 


In  one  case  the  fetal  skin  was  the 


348  ABNORMAL   PREGXANX'Y. 

In  the  mother  has  been  found  Bright's  disease,  heart  disease,  or 
liver  disease,  causing  anasarca  and  dropsy  of  the  cavities  of  the  trunk  ; 
syphilis,  leukemia,  or  anaemia. 

Symptoms. — Hydramnion  causes  a  great  distention  of  the  abdomen. 
As  a  rule,  it  develops  slowly  towards  the  end  of  pregnancy.  Usually 
the  uterus  is  felt  distinctly  fluctuating,  but  sometimes  it  is  so  tense 
that  no  fluctuation  is  perceived,  and  it  feels  quite  hard.  Per  vaginam 
we  feel  the  lower  uterine  segment  bulge  downward,  and  the  cervix 
drawn  high  upward  and  backward.  It  may  be  obliterated  and  the 
OS  dilated,  but,  strange  enough,  the  ovum  itself  is  flaccid.  As  a  rule, 
no  presenting  part  is.  felt,  because  the  fetus  occupies  an  abnormal  situ- 
ation. Through  the  abdominal  w^all  the  uterus  is  felt  having  a  globu- 
lar shape,  a  great  deal  of  water  is  displaced  before  we  reach  the 
fcetus,  often  the  small  parts  cannot  be  felt  at  all,  and  the  larger  por- 
tions of  the  fcetus,  as  well  as  the  jDlace  where  the  fetal  heart  is  heard 
easily,  shift  position. 

The  great  distention  of  the  uterus  causes  neuralgia,  dyspnoea,  and 
swelling  of  the  lower  extremities,  or  even  thrombosis  of  a  vein. 

Diagnosis. — If  we  are  sure  that  the  patient  is  pregnant,  there  is 
no  difficulty  in  diagnosticating  hydramnion.  Otherwise  her  condition 
might  be  due  to  an  ovarian  cyst.  Great  attention  should  therefore  be 
paid  to  the  fetal  heart-sound. 

Prognosis. — The  prognosis  for  both  mother  and  child  is  less  good 
than  in  normal  pregnancy.  Hydramnion  not  only  causes  discomfort 
and  suffering,  but  labor  may  set  in  prematurely,  or  the  interference 
with  circulation  may  become  so  great  that  induction  of  premature  labor 
becomes  necessary.  The  sudden  escape  of  a  large  amount  of  liquor 
amnii  and  consequent  lack  of  blood  in  brain  or  heart  may  cause  loss 
of  consciousness  or  heart  failure.  The  placenta  is  apt  to  become  de- 
tached before  the  time,  and  the  overstretched  uterus  may  not  contract 
well,  W' hich  again  may  cause  tedious  labor  or  hemorrhage  after  the  birth 
of  the  child.     Faulty  presentation  may  call  for  operative  interference. 

For  the  child  the  prognosis  is  still  more  serious.  Many  of  the 
children  die  either  during  labor  or  shortly  after.  They  are  often 
atrophic  or  malformed.  The  premature  detachment  of  the  placenta 
may  cost  the  child  its  life,  and  the  faulty  presentation  also  militates 
against  it. 

Treatment. — The  membranes  should  be  punctured,  care  being  taken 
not  to  let  all  the  water  run  off  suddenly.  Since  the  foetus  often  is 
small  and  weak,  the  induction  of  premature  labor  should  be  deferred 
as  long  as  possible. 

Acute  Hydramnion. — We  have  said  that,  as  a  rule,  hydramnion 
develops  gradually  towards  the  end  of  pregnancy,  but  there  is  a  form 
of  the  disease  which  develops  in  the  middle  of  pregnancy,  between  the 


DISEASES    OF   THE    OVUM.  349 

fourth  and  the  sixth  month,  reaches  in  a  very  short  time  large  pro- 
portions and  is  accompanied  by  pain  and  vomiting.  This  form  is 
found  with  twins  occupying  a  single  ovum.  Only  one  amnion  is 
affected.  The  explanation  probably  is  that  one  foetus  has  a  stronger 
heart  than  the  other.  By  its  contractions  the  blood  is  driven  to  the 
other  heart,  where  a  stasis  is  developed  with  hypertrophy  of  heart  and 
kidneys  and  consequent  transudation  into  the  amniotic  sac. 

§  3.  Scanty  Liquor  Amnii. — The  amount  of  liquor  amnii  may  be 
reduced  to  a  tablespoonful.  The  cause  is  in  most  cases  unknown.  In 
one  it  was  closure  of  the  fetal  urethra.  The  condition  may  seriously 
interfere  with  the  development  and  mobility  of  the  foetus.  Otherwise 
it  is  of  no  practical  importance. 

§  4.  Cystic  Deg-eneration  of  the  Villi  of  the  Chorion ;  Vesicular 
Mole. — This  disease  is  sometimes  called  uterine  hydatid,  an  unfor- 
tunate name  based  on  the  totally  erroneous  idea  that  the  vesicles 
that  characterize  it  were  analogous  to  those  produced  by  echinococci. 
It  is  a  cystic  degeneration  of  the  villi  of  the  chorion,  which  may  extend 
over  the  whole  surface  of  the  ovum,  or  be  limited  to  the  placenta 
or  even  to  a  part  of  the  same.  Sometimes  the  degeneration  has 
progressed  so  far  that  there  is  no  trace  of  foetus  or  umbilical  cord ; 
nay,  even  the  amniotic  cavity  may  have  disappeared,  so  that  nothing 
is  left  but  a  mass  of  vesicles  and  pedicles  having  some  resemblance  to 
a  bunch  of  grapes  (Figs.  272,  273).  In  other  cases  there  may  be  an 
amniotic  cavity,  with  or  without  foetus  ;  and  hnally  the  morbid  process 
may  be  so  limited  that  the  foetus  is  developed  normally  and  the  child 
is  born  alive  and  viable. 

Wlien  the  degeneration  extends  over  a  large  portion  of  the  ovum, 
the  decidua  is  perforated  by  it,  and  sometimes  the  degeneration  works 
its  way  into  the  muscular  coat  of  the  uterus,  or  it  may  even  perforate 
the  peritoneum,  causing  death  by  intraperitoneal  hemorrhage. 

The  diseased  mass  consists  of  vesicles  and  pedicles  intimately  con- 
nected with  the  decidua.  The  vesicles  vary  in  size  from  a  pin's  head 
to  a  hen's  e^^^  and  are  colorless  and  translucent.  The  smaller  are 
semi- solid,  much  like  the  gelatin  of  Wharton  in  the  umbilical  cord ; 
but  the  larger  they  are,  the  more  watery  is  the  fluid.  It  contains 
albumin  and  mucin,  but  the  latter  diminishes  with  the  development  of 
the  vesicles.  While  the  smaller  vesicles  contain  blood-vessels,  these 
disappear  in  the  larger.  The  pedicles  are  very  thin,  mostly  solid,  but 
sometimes  hollow.  The  distribution  differs  from  that  in  a  bunch  of 
grapes  in  so  far  as  not  all  vesicles  have  a  pedicle  of  their  own, 
springing  directly  from  the  main  trunk  or  its  branches.  One  vesicle 
may  become  connected  with  another,  the  pedicle  swelling  up  in  several 
points  to  form  vesicles  like  the  beads  on  a  rosary.  If  the  intervening 
stalk  is  hollow,  the  fluid  may  be  pressed  from  one  vesicle  into  the 


350 


ABNORMAL   PREGNANCY. 


other.  The  whole  mass  may  grow  to  the  size  of  an  adult's  head  and 
weigh  three  or  four  pounds. 

The  process  begins  as  a  cell  proliferation  in  the  syncytium  and 
the  epithelium  of  the  villi,  and  the  connective  tissue  forming  their 
stroma  is  liquefied. 

In  most  cases  the  degeneration  leads  to  abortion  in  the  fourth  or 


Fig.  272. 


,.  o 


Cystic  degeneration  of  villi  of  the  chorion. 


fifth  month,  but  in  some  the  morbid  mass  has  remained  in  the  uterus 
and  even  continued  to  grow  for  twelve  or  thirteen  months. 

In  twin  pregnancies  one  ovum  may  be  healthy,  the  other  the  site 
of  a  vesicular  mole. 

The  etiology  is  unknown.  The  disease  is  more  common  in  advanced 
age  than  among  young  women.  The  same  woman  may  be  thus  affected 
in  several  pregnancies.    Some  suppose  therefore  that  there  is  a  maternal 


DISEASES    OF    THE    OVUM. 


351 


predisposition  before  pregnancy,  probably  an  endometritis.  The 
disease  is  rather  rare. 

Symptoms. — In  the  beginning  the  growth  of  the  uterus  may  remain 
behind  the  norm,  but  later  the  organ  grows  much  faster  than  one 
containing  only  a  normal  foetus.  Very  often  hemorrhages  occur. 
Some  vesicles  may  be  expelled,  which  settles  the  diagnosis  at  once. 
Otherwise  we  are  compelled  to  rely  upon  the  combination  of  the  two 
other  symptoms,  hemorrhage  and  unusual  size  of  the  uterus. 

The  prognosis  is  rather  serious.  Not  only  may  the  mother  be 
weakened  by  repeated  hemorrhages,  or  even  die  in  consequence  of 
them,  but  the  very  dangerous  disease  known  as  deciduoma  malignum 

Fto.  27.S, 


Uterus  containing  a  vesicular  mole.    (Ahlfeld.) 

has  been  particularly  found  to  follow  the  expulsion  of  a  vesicular  mole. 
Sometimes  the  vesicular  mole  has  been  found  in  women  suffering  from 
albuminuria,  and  then  the  prognosis  is  very  much  worse. 

As  to  the  foetus,  it  is  mostly  destroyed  or  killed  by  the  disease, 
which  blocks  up  the  channels  of  nutrition  and  respiration. 

Treatment. — In  the  earlier  months  the  case  should  be  treated  as  we 
have  described  in  speaking  of  abortion.  The  writer  has  dilated  the 
cervix  in  the  third  month  and  curetted  with  Simon's  sharp  spoon, 
the  morbid  tissue  removed  filling  an  eight-ounce  glass,  without  losing 
more  blood  than  usual  and  without  an  untoward  symptom  during  the 
convalescence.  When  the  tumor  is  large,  the  curette,  even  a  blunt 
one,  becomes  a  very  dangerous  instrument  on  account  of  the  possible 
extension  of  the  diseased  tissue  into  the  wall  of  the  uterus.  The 
cervix  must  be  fully  dilated  with  instruments  and  manually,  and  pres- 
sure should  be  exercised  on  the  fundus.  As  the  tissue  of  the  mole  is 
very  brittle,  the  accoucheur  should  not  pull  on  it,  but  try  to  deliver 
the  whole  growth  in  one  piece.  If  pressure  does  not  suffice,  he  must 
introduce  two  fingers  or  his  whole  hand  and  use  his  nails  as  curette. 


352 


ABNORMAL    PREGNANCY. 


Since  there  may  be  a  weak  point  in  the  uterine  wall,  it  is  better  not  to 
use  intra-uterine  irrigation.  Hemorrhage  must  be  combated  with 
intra-uterine  and  vaginal  tamponade,  ergot,  and  faradization. 

If  a  malignant  tumor  develops,  the  whole  uterus  must  be  removed 
by  vaginal  hysterectomy. 

§  5.  Cellular  Hypertrophy  and  Hyperplasia  of  the  Villi,  or 
Myxoma  Pibrosum  Placentae. — Some  of  the  villi  of  the  chorion  may 
form  roundish,  smooth,  hard  nodules  in  the  placenta.  If  such  a 
degeneration  of  the  villi  spread  much  over  the  placenta,  it  would 
interfere  with  the  nourishment  and  respiration  of  the  foetus.  So  far 
the  cases  have  had  only  pathological  interest. 

§  6.  Diseases  of  the  Decidua. — Atrophy  of  Decidua. — The  reflexa 
may  be  so  little  developed  that  it  covers  only  part  of  the  ovum  (Fig. 
274),  or  there  may  be  places  where  it  is  thin.     The  serotina  may 

occupy  so  small  an  area  that  the 
Fig.  274.  ovum  becomes  pedunculated  and 

the  foetus  imperfectly  developed. 
Hypertrophy  and  Hyperplasia 
OF  THE  DEcmuA. — On  the  other 
hand,  the  decidua  may  be  of  un- 
usual thickness.  It  may  then  be 
retained  at  the  time  of  expulsion 
and  necessitate  manual  removal. 
Cystic  Decidua. — Cysts  may 
form  in  the  decidua. 

Hemorrhagic  Endometritis. — 
The  spongy  tissue  of  the  decidua 
is  very  apt  to  tear,  so  that  blood  is  extravasated  into  it  and  drives  the 
chorion  and  amnion  before  it,  forming  protuberances  on  the  inside  of 
the  ovum  (Fig.  275).  The  foetus  may  be  destroyed,  hemorrhages  may 
be  repeated,  and  the  ovum  transformed  into  a  solid  mass,  mostly  com- 
posed of  coagulated  blood  and  villi  of  the  chorion  and  filling  the 
uterus — a  so-called /esA^/  mole  {Fig.  276). 

All  these  morbid  conditions  of  the  decidua,  as  a  rule,  end  in 
abortion. 

Hydrorrhcea  Gravidarum.— During  pregnancy  there  may  be  from 
the  interior  of  the  uterus  a  watery  discharge  of  decidual  or  amniotic 
origin.  The  decidual  hydrorrhoea  is  due  to  chronic  endometritis.  A 
serous  fluid  accumulates  between  the  decidua  vera  and  reflexa,  and 
is  from  time  to  time  expelled  to  the  amount  of  several  ounces  or  even 
a  quart.  After  the  free  flow  an  oozing  follows,  which  may  continue 
for  several  hours  or  days.  It  then  stops  or  may  be  replaced  by  a  new 
copious  discharge,  a  condition  that  may  go  on  for  weeks  or  months. 
Exceptionally  it  may,  however,  end  in  abortion. 


Imperfect  development  of  decidua  reflexa. 
(Duncan.) 


DISEASES    OF   THE    OVUM. 


353 


In  amniotic  hydroi^rhoea  a  watery  fluid  may  accumulate  between 
the  amnion  and  the  chorion,  until  the  latter  ruptures,  or  the  amnion 


Fig.  275. 


Apoplectic  ovum,  the  effused  blood  forming  protuberances. 


Fig.  276. 


P'leshy  mole.     (Wood's  Museum,  Bellevue  Hospital,  No.  IVS^.) 


and  chorion  may  be  ruptured  together.     The  rupture  may  take  place 
at  some  distance  above  the  os,  in  which  case  the  bag  of  waters  may 


354  ABNORMAL    PREGNANCY. 

form  during  labor,  although  liquor  amnii  had  already  escaped  during 
pregnancy.  The  membranes  have  even  been  found  perforated  in  their 
whole  thickness  by  a  small  circular  opening  situated  above  the  tear 
through  which  the  foetus  has  passed. 

The  amniotic,  like  the  decidual,  hydrorrhoea  may  be  repeated  and 
continue  for  weeks,  but  usually  soon  ends  in  abortion  or  labor. 

Diagnosis. — If  the  fluid  can  be  collected,  the  entirely  characteristic 
composition  of  the  amniotic  fluid,  with  its  masses  of  free  fat,  cells  filled 
with  fat,  and  lanugo,  at  once  settles  the  question  whether  we  have  to 
deal  with  the  decidual  or  amniotic  form  of  hydrorrhoea.  But,  as  a  rule, 
the  fluid  is  not  available  for  examination.  If  after  one  or  more  flows 
the  oozing  stops  altogether  for  weeks,  it  is  certain  that  the  fluid  came 
from  the  decidua.  If  a  very  large  amount  is  expelled  at  one  time,  say 
a  pint  or  more,  and  oozing  continues  all  the  time,  the  fluid  must  have 
come  from  the  amnion,  and  labor  will  soon  follow. 

The  amniotic  form  of  hydrorrhcea  is  of  greater  importance  than  the 
decidual.  The  patient  should  avoid  all  violent  movements,  and  it  is  best 
to  keep  her  in  bed  altogether.  We  should  also  do  all  we  can  to  postpone 
labor  by  means  of  hypodermic  injections  of  morphine,  suppositories 
with  opium,  and  the  fluid  extract  of  viburnum  given  by  the  mouth. 

§  7.  Anomalies  of  the  Placenta. — In  the  first  part  of  this  work 
we  have  already  mentioned  double  placenta  (p.  69  with  Fig.  95)  and 
the  hattledoor  placenta  (p.  70  with  Fig.  96). 

Calcareous  incrustations  are  very  common  both  in  the  maternal  and 
the  fetal  part  of  the  placenta. 

White  infarct  is  also  quite  frequent.  It  begins  as  an  endarteritis 
in  the  villi  of  the  chorion,  which  leads  to  necrosis  of  the  tissue  and 
formation  of  fibrin,  that  coagulates  and  forms  in  the  placenta  hard 
white  nodules  raised  above  the  level  of  the  fetal  surface.  If  this 
degeneration  is  wide-spread,  it  may  cause  the  death  of  the  foetus. 

There  may  also  be  a  red.,  or  hemorrhagic .^  infarct,  consisting  of 
coagulated  blood  which  comes  from  the  blood-vessels  of  the  decidua, 
and  is  pressed  in  between  the  villi  of  the  chorion. 

A  placental  abscess  is  an  exceedingly  rare  occurrence. 

On  the  other  hand,  an  unusually  tight  adhesion  between  the  pla- 
centa a.nd  the  uterus  is  not  very  rare,  and  is  due  to  decidual  endo- 
metritis. 

The  placenta  may  be  spread  more  or  less  over  the  whole  ovum, 
and  then  it  does  not  form  the  normal  compact  body,  but  is  thin  and 
flabby — membranous  placenta. 

Sometimes  there  is  a  well-formed  placenta,  but  besides  that  there 
are  one  or  more  detached  portions  of  placental  structure — placentce 
succenturiatce.  They  are  of  considerable  practical  interest,  as  they 
may  be  overlooked,  remain  behind,  and  give  rise  to  puerperal  infection. 


DISEASES    OF   THE   OVUM. 


355 


Fig.  277. 


Occasionally  the  fetal  surface  of  the  placenta  shows  near  its  cir- 
cumference a  white  fibrinous  ring,  over  which  the  villi  extend,  while 
the  amnion  starts  from  its  inner  margin — placenta  marginata. 

All  sorts  of  tumors — myxoma,  fibroma,  angioma,  sarcoma,  and 
cysts — are  occasionally  found  in  the  placenta. 

§  8.  Anomalies  of  the  Umbilical  Cord. —  Too  Great  Length. — The 
cord,  which  normally  is  about  twenty  inches  long,  may  have  a  length 
of  a  yard  or  more.  The  longest  that  has  been  put  on  record  meas- 
ured seventy  inches.  This  abnormality  is  apt  to  lead  to  coiling  around 
the  foetus  or  to  prolapse. 

Coiling. — The  cord  is  very  frequently  wound  around  the  neck. 
If  it  only  goes  around  once  or  twice,  there  is  no  serious  danger, 
the  cord  being  easily  pulled  over  the  head  by  the  accoucheur ;  but 
if  the  cord  is  wound  many  times  around  the  neck  and  the  circles  are 
drawn  tight,  it  may  cause  the  death  of  the  foetus.  In  one  such  case 
there  were  eight  tours.  The  danger  is  increased  considerably  if  the 
cord  is  at  the  same  time  wound  around  an  extremity, 
whereby  it  may  become  so  tense  as  to  cause  the  strangu- 
lation of  the  foetus.  In  encircling  the  body  it  may  leave 
a  depression  in  the  soft  parts,  and  when  it  is  wound 
around  a  limb  it  may  even  cut  the  soft  parts  to  the  bone. 

True  Knots. — Sometimes  one  or  more  knots  (Fig. 
277)  are  found  on  the  cord,  which  are  formed  by  the 
coil  around  the  foetus  becoming  loosened  and  the  foetus 
slipping  through  it.  They  rarely  endanger  the  life  of 
the  foetus. 

False  knots  are  only  irregular  accumulations  of  the 
gelatin  of  Wharton.  They  are  exceedingly  common  and 
without  importance. 

Torsion. — The  cord  may  become  so  twisted  that  the 
circulation  through  it  is  interfered  with  and  the  foetus 
dies  (Fig.  278). 

Stenosis. — The  lumen  of  the  umbilical  vein  or  arteries 
may  in  some  places  be  so  small  as  to  oppose  a  serious  obstacle  to 
circulation.  This  is  especially  the  case  with  the  openings  left  by  the 
valves  and  diaphragms  found  in  the  interior  of  the  umbilical  vessels. 
Such  narrowing  may  cause  the  death  of  the  foetus. 

Too  Short  Cord. — Exceptionally  the  cord  may  be  too  short.  In 
one  case  it  has  even  been  reported  as  measuring  only  one  and  a  half 
inches.  This  may,  as  we  shall  see  later,  become  a  serious  obstacle 
during  labor. 

§  9.  Chang-es  in  the  Foetus  after  its  Death. — After  death  a  small 
foetus  may  entirely  disappear,  while  the  growth  of  the  ovum  continues 
for  several  months,  and  the  whole  is  converted  into  a  fleshy  mole.     A 


True  knot  of 
umbilical  cord. 


356  ABXORMAL    PREGXAXCY. 

larger  foetus  may  undergo  either  maceration  or  mummification,  Avhile 
no  putrefaction  takes  place :  there  is  no  odor  of  decaying  animal 
tissue,  and  the  saprophytes  have  not  gained  admission  to  the  uterine 
cavity. 

In  the  macerated  fretus  [fcetus  sanguinolentus)  all  the  blood  has  disap- 
peared from  the  organs,  the  red  blood-corpuscles  hare  been  dissolved, 

Fig.  278. 


Torsion  of  umbilical  cord. 

and  the  whole  body,  especiahy  the  connective  tissue,  is  infiltrated  with 
a  reddish  serum.  The  epidermis  is  lifted  up  into  vesicles  filled  with 
such  sanguinolent  fluid  or  torn  off,  hanging  in  shreds,  and  exposing  a 
dark-red  corium.  The  head  forms  a  shapeless  sac  containing  the 
more  or  less  loosened  cranial  bones  and  a  reddish-brown  mass  repre- 
senting the  brain,  the  structure  of  which  is  effaced.  The  muscles  are 
imbued  with  serum  and  softened,  the  fibrillas  contain  fat  granules,  but 
their  striation  is  mostly  preserved.  The  lungs  may  still  be  inflated. 
The  liver  is  much  decomposed,  the  cells  being  transformed  into  a  fatty 
detritus  mixed  with  pigment.  In  all  other  organs  the  parenchyma  is 
in  a  condition  of  granular  cloudiness,  and  often  they  are  covered  with 
a  whole  layer  of  crystals  of  margarin,  cholesterin,  and  pigment. 

The  mummified  foetus  is  dry,  shrunken,  and  covered  with  a  yellow 
skin.  Mummification  is  found  especially  in  foetuses  who  have  died 
from  coiling  of  the  umbilical  cord  around  the  neck  or  in  twin  pregnan- 
cies, where  one  twin  dies  and  becomes  compressed  by  the  survivmg 
foetus  until  the  former  by  lateral  compression  is  reduced  to  a  thin  pad 
like  a  ginger-bread  figure— /os^us  papyraceus. 


PART    II.— ABNORMAL    LABOR    (DYSTOCIA). 

Labor  does  not  always  run  so  smoothly  as  we  have  described  it 
above.  Quite  the  contrary.  There  are  numerous  conditions  or  acci- 
dents that  cause  a  deviation  from  the  normal,  render  childbirth  diffi- 
cult or  impossible,  and  jeopardize  the  life  of  the  mother,  the  child,  or 
both. 

The  trouble  may  arise  from  faulty  expellant  forces ;  from  the 
presentation,  position,  attitude,  or  size  and  shape  of  the  foetus  ;  from 
multiple  fetation  ;  from  abnormalities  in  the  ovum ;  or  from  some 
obstruction  in  the  parturient  canal.  The  act  may  be  complicated  by 
hemorrhage,  convulsions,  or  injury  to  the  soft  parts  or  the  bony  struc- 
tures. The  accoucheur  must  know  all  these  possibilities  ;  he  must  be 
able  to  recognize  them  when  they  arise  or  threaten ;  he  must  know 
how  to  prevent  them  or  remedy  them  ;  or  he  m.ust  at  least  know  the 
limits  of  his  own  knowledge  and  capacity,  so  as  to  be  able  to  secure 
the  necessary  assistance  or  the  co-operation  of  men  possessing  deeper 
insight,  larger  experience,  or  greater  skill. 


CHAPTER   I. 

FAULTY   UTERINE    CONTRACTIONS. 

Uterine  contractions  may  be  too  weak  or  come  on  with  too  long 
intervals ;  on  the  other  hand,  they  may  be  too  strong  or  continuous 
instead  of  being  intermittent ;  and  they  may  be  accompanied  by  an 
unusual  amount  of  pain. 

Inertia  of  the  uterus,  or  too  weak  contraction,  is  a  common 
condition,  and  of  very  different  importance  according  to  the  time  of  its 
occurrence.  It  may  be  primary  or  secondary.  There  may  be  too 
long  intervals  between  contractions,  or  they  may  be  of  so  short  dura- 
tion and  so  inefficient  that  they  have  no  effect  on  opening  up  the 
uterus,  so  that  the  first  stage  may  become  protracted  over  several  days. 
As  long  as  the  membranes  are  unruptured,  this  condition  has  no  in- 
fluence on  the  child,  and  little  on  the  mother,  except  that  it  may  be 
annoying  to  her,  tax  her  patience,  and  make  her  nervous.  In  the 
second  stage  deficient  contractions  are  much  more  serious  both  to 
mottier  and  child.  The  water  may  drain  off  and  the  vagina  become 
hot  and  dry.  In  the  third  stage  deficient  uterine  contraction  is  of  still 
greater  importance  and  may  become  the  cause  of  fatal  hemorrhage. 

Etiology. — Frequent  childbirths  predispose  to  it.     Likewise  general 

357 


358  ABNORMAL    LABOR. 

debility  due  to  illness  or  a  weak  constitution.  The  musculature  of  the 
uterus  may  be  too  little  developed,  which  is  particularly  found  in  a 
bicornute  uterus.  The  muscular  tissue  has  been  found  infiltrated  with 
small  round  cells,  characteristic  of  metritis  ;  and  chronic  endometritis 
is  often  the  starting-point.  If  the  abdomen  is  much  distended,  as  in 
hydramnion  or  twin  pregnancy,  the  uterine  fibres  work  at  a  disad- 
vantage and  cannot  get  a  purchase.  The  use  of  chloroform  is  almost 
constantly  accompanied  by  a  w^eakening  of  the  uterine  contractions. 
Too  rapid  removal  of  the  placenta  or  its  retention  in  the  uterine 
cavity  often  leads  to  deficient  contraction  in  the  third  stage.  Some- 
times the  cause  is  to  be  found  in  a  distended  bladder  or  a  loaded 
bowel.  At  other  times  there  may  be  an  unfavorable  position  of  the 
uterus, — as  in  a  pendulous  abdomen.  But  the  beginner  must  be 
warned  that  in  the  great  majority  of  cases  insufficient  contraction  is 
due  to  some  mechanical  disproportion  between  the  child  and  the 
parturient  canal.  Especially  is  this  the  case  with  the  secondary 
weakness,  when  there  have  been  good,  perhaps  even  strong,  contrac- 
tions in  the  beginning  and  they  later  give  out.  Before  arriving  at  the 
diagnosis  of  too  weak  uterine  contractions,  he  should  therefore  care- 
fully scrutinize  the  whole  field. 

Treatment. — In  the  opening  stage,  the  patient  should  not  lie  in  bed, 
but  sit  in  a  rocking-chair  or  walk  about,  or  she  may  even  to  advantage 
attend  to  some  household  duty.  We  should  endeavor  to  calm  her 
mind  and  encourage  her  to  be  patient.  Large  vaginal  injections  with 
hot  water  are  not  so  much  in  use  now  as  some  years  ago,  before 
our  attention  had  been  called  to  the  danger  of  microbic  infection. 
Still,  by  using  a  mild  antiseptic  fluid, — say,  one-half  of  one  per 
cent,  lysol, — the  danger  may  be  obviated,  and  the  remedy  is  some- 
times effective.  I  have  often  seen  excellent  result  from  the  introduc- 
tion of  a  rubber  bag  into  the  vagina  and  its  inflation  with  sterilized 
salt  solution  or  lysol.  Still  more  powerful  is  the  insertion  of  a  bougie 
through  the  cervix  into  the  interior  of  the  womb.  If  by  so  doing  we 
rupture  the  membranes,  not  much  is  lost,  since  this  is  in  itself  a 
method  to  bring  on  uterine  contractions  ;  but  if  possible  it  should  be 
avoided,  since  it  is  much  better  for  both  mother  and  child  to  have 
labor  follow  the  natural  course.  Premature  rupture  of  the  membranes 
often  leads  to  compression  of  the  cervix  between  the  brim  of  the  pelvis 
and  the  head  of  the  child,  causing  great  pain  and  retarding  labor.  If 
the  OS  is  somewhat  dilated,  Barnes's  dilators  may  be  used,  and  if 
necessary,  followed  by  Champetier  de  Ribes's  unelastic  bag  (see  Oper- 
ations). 

Sometimes  mild  friction  of  the  abdominal  wall  against  the  fundus 
uteri  increases  the  strength  of  uterine  contractions  or  brings  them  on. 
For  this  purpose,  the  accoucheur,  sitting  at  the  bedside,  seizes  the 


FAULTY   UTERINE    CONTRACTIONS.  359 

abdominal  wall  in  front  of  the  fundus  and  slides  it  gently  from  side 
to  side  or  in  an  anteroposterior  direction.  If  this  does  not  suffice, 
he  may  exercise  more  decided  jiressure  on  the  fundus. 

Even  a  mild  galvanic  current  is  recommended  for  the  purpose  of 
bringing  on  contractions,  one  pole  being  placed  above  the  symphysis, 
the  other  at  the  fundus. 

The  contractions  remaining  unsatisfactory,  it  may  become  neces- 
sary to  end  labor  by  means  of  the  forceps.  This  is  an  obstetric 
instrument  consisting  of  two  blades  which  are  applied  to  the  fetal 
head  and  serve  to  pull  it  out  of  the  genital  canal  (see  Operations). 

The  measures  to  be  taken  during  the  third  stage  will  be  con- 
sidered below  under  Hemorrhage. 

As  to  drugs  the  writer  would  warn  against  the  administration  of 
ergot,  a  substance  which  is  apt  to  produce  tetanic  contraction  and 
interferes  much  with  all  other  measures.  It  should  therefore  be 
reserved  not  only  for  the  third  stage,  but  should  not  be  given  until  it 
is  sure  that  no  surgical  interference  will  be  called  for.  Considerable 
benefit  may  be  derived  from  antipyrin  given  in  doses  of  ten  grains 
every  half-hour,  half  a  drachm  in  all.  Quinine  has  undoubtedly  the 
property  of  strengthening  weak  contractions,  but  is  apt  to  cause 
hemorrhage  in  the  third  stage.  If  the  cause  of  the  weak  contractions 
is  to  be  found  in  their  painfulness,  nothing  works  as  well  as  a  hypo- 
dermic injection  of  morphine  or  a  few  whiffs  of  chloroform. 

Too  Strong  or  too  Frequent  Contractions. — In  some  women 
the  uterine  contractions  show  an  unusual  violence.  If  there  is  no 
obstruction  in  the  genital  canal,  this  leads  to  a  premature  expulsion 
— so-called  precipitate  labor — which  may  have  serious  results.  The 
child  may  be  born  before  the  mother  has  made  proper  arrangements 
for  its  birth.  Labor  may  come  on  and  run  its  course  while  the 
woman  is  sitting  on  a  bench  in  a  public  park  or  riding  in  a  car.  Or 
she  may  think  she  is  going  to  have  an  alvine  evacuation,  and  while 
she  is  sitting  in  the  water-closet  the  child  is  expelled  into  the  hopper. 
If  the  OS  is  not  dilated,  the  cervix  may  be  torn.  If  former  childbirths 
have  not  left  a  wide  entrance  to  the  vagina,  the  perineum  may  be 
torn.  These  lacerations  or  the  premature  detachment  of  the  placenta 
may  give  rise  to  hemorrhage.  The  mother  may  faint  on  account 
of  the  sudden  lack  of  resistance,  or  she  may  lose  all  self-control 
and  become  delirious.  The  child  may  fall  on  the  ground  and  sustain 
injuries  to  its  head,  or  the  navel-string  may  be  torn.  If  this  happens 
at  some  distance  from  its  insertion  on  the  abdomen  of  the  child,  the 
vessels  may  contract,  whereby  loss  of  blood  is  avoided,  but  an 
avulsion  at  or  near  the  skin  is  apt  to  become  the  source  of  a  fatal 
hemorrhage.  These  injuries  to  the  child  are  particularly  liable 
to  happen  if   it  is  expelled  while  the  mother   is   standing  up  ;    but 


360  ABNORMAL  LABOR. 

fortunately,  as  a  rule,  she  instinctively  lowers  herself  to  a  crouching 
posture,  which  exposes  the  child  much  less  to  being  wounded.  If, 
however,  birth  takes  place  while  the  mother  is  sitting  on  a  water- 
closet  or  a  privy,  the  child  may  fall  into  the  water  or  the  dung  and 
drown  or  become  smothered. 

If  there  is  a  serious  obstruction  somewhere  in  the  genital  tract,  the 
condition  becomes  very  serious  for  mother  and  child.  The  mother 
becomes  agitated,  her  face  is  red,  the  pulse  is  full  and  rapid.  She  is 
prone  to  use  abdommal  pressure  before  the  soft  parts  are  properly 
dilated. 

Etiology. — In  some  families  the  women  have  an  hereditary  dispo- 
sition to  precipitate  labor.  Too  frequent  or  violent  vaginal  examina- 
tion is  apt  to  cause  undue  strength  of  the  uterine  contractions.  Some- 
times the  patient  is  herself  at  fault  by  throwing  herself  impatiently 
from  side  to  side  or  using  the  abdominal  pressure  during  the  opening 
stage. 

Treatment. — When  contractions  are  too  severe  or  too  frequent  and 
there  is  no  obstruction,  they  should  be  mitigated  by  hypodermic  injec- 
tions of  morphine  or  the  administration  of  an  enema  with  tincture  of 
opium  or  chloral,  or  by  inhalation  of  chloroform.  The  patient  should 
be  deprived  of  all  means  by  which  she  can  increase  abdominal  press- 
ure, such  as  support  for  arms  and  feet ;  she  should  be  told  not  to 
bear  down.  She  should  be  placed  in  the  left-side  position,  and  the 
presenting  part  should  be  pressed  back  with  the  palm  of  the  hand  so 
as  to  prevent  too  sudden  a  passage  through  the  vulva. 

Too  Frequent,  but  too  Weak  Contractions. — Sometimes  the  con- 
tractions come  too  frequently,  but  are  of  short  duration  and  of  little  or 
no  effect.  For  this  condition  the  hypodermic  injection  of  morphine 
is  the  best  remedy. 

Tetanic  Contractions. — The  contractions  may  last  too  long,  and 
come  on  so  rapidly  that  there  is  hardly  any  interval  between  them,  or 
they  may  even  become  continuous,  a  condition  designated  as  tetanus 
of  the  uterus.  This  wears  out  the  strength  of  the  patient,  and  may  so 
interfere  with  placental  respiration  or  cause  such  pressure  on  the 
umbilical  cord  that  the  foetus  dies. 

This  tetanic  contraction  may  be  due  to  premature  rupture  of  the 
membranes  with  the  escape  of  all  the  liquor  amnii,  to  cross  presenta- 
tion, a  narrow  pelvis,  or  any  other  serious  impediment  to  the  expul- 
sion of  the  child. 

Treatment. — Symptomatically  chloroform  is  the  chief  remedy,  but 
in  connection  with  its  administration  the  accoucheur  must  look  for  the 
cause  and  use  appropriate  measures  for  its  removal. 

Too  Painful  Uterine  Contractions. — Normally  every  uterine  con- 
traction is  accompanied  by  a  certain  amount  of  pain,  which  varies 


FAULTY   ABDOMINAL   PRESSURE.  361 

much  in  intensity  in  different  individuals,  but  sometimes  the  sensation 
of  pain  is  out  of  all  proportion  to  the  contraction,  and  even  interferes 
with  it.  In  such  cases  we  must  have  recourse  to  chloroform  at  an 
unusually  early  stage. 


CHAPTER   II. 
FAULTY  ABDOMINAL    PRESSURE.   . 

Under  ordinary  circumstances  it  is  chiefly  during  the  stage  of 
expulsion  that  abdominal  pressure  comes  into  play.  When  the  os  is 
fully  dilated,  the  membranes  rupture,  and  the  foetus  begins  to  distend 
the  vagina,  the  abdominal  muscles  contract  in  consequence  of  a  reflex 
action.  But  even  during  the  stage  of  dilatation  the  abdominal  wall  by 
its  tonus  offers  a  support  for  the  contracting  uterus. 

The  abdominal  pressure  may  be  absent  altogether  or  too  weak 
or  too  strong  or  premature.  Cases  have  been  observed  where,  in 
consequence  of  a  fracture  of  the  spinal  column,  there  was  a  complete 
paralysis  of  the  abdominal  muscles.  In  cases  of  cleft  pelvis  the  mus- 
cles lack  the  necessary  fixation.  A  woman  who  gives  birth  to  a  child 
after  having  undergone  tracheotomy,  and  while  she  is  still  wearing 
a  canula  in  her  trachea,  cannot  effect  that  closure  of  the  windpipe 
which  is  a  requisite  for  the  production  of  abdominal  pressure.  Others 
suffering  from  dyspnoea  in  consequence  of  heart  or  lung  trouble  can 
only  make  an  imperfect  effort.  .  Others  again  are  pusillanimous.  Hav- 
ing been  spoiled  or  pampered  in  luxury,  they  are  unaccustomed  to 
pain  and  self-control,  and  have  not  the  courage  to  press  down  when 
they  feel  the  pain  increase  thereby.  In  deep  anaesthesia  the  power  of 
contraction  is  lost,  and  the  abdominal  wall  becomes  quite  flaccid.  In 
some  multiparous  women  there  is  such  a  diastasis  between  the  recti 
muscles  that  the  uterus  enters  between  them  instead  of  being  com- 
pressed by  them.  Large  herniae,  abdominal  tumors,  tympanites,  peri- 
tonitis, twin  pregnancies,  hydramnion,  or  an  overdistended  bladder 
may  interfere  with  proper  contraction  of  the  abdominal  muscles.  If 
the  corpus  uteri  by  its  contraction  has  pushed  the  foetus  into  the  cervix 
and  vagina,  it  can  do  no  more,  and  if  then  there  is  no  abdominal 
pressure  labor  must  stop. 

Too  early  or  too  forcible  abdominal  pressure  exposes  the  patient  to 
tears  of  the  soft  parts  of  the  genital  canal.  In  some  rare  cases  the 
sternum  has  been  fractured  transversely.  If  some  alveoli  of  the  lung 
give  way  under  the  violent  pressure,  the  air  may  find  its  way  under 
the  skin,  forming  an  emphysema  of  the  face,  the  neck,  and  the  thorax. 

Treatment. — In  cases  of  absence  or  too  great  weakness  of  contrac- 
tion we  should  try  to  find  the  cause  and  to  remove  it.     We  must  en- 


362  ABNORMAL    LABOR. 

courage  the  patient  and  explain  to  her  the  necessity  of  bearing  down, 
promising  her  that  if  it  increases  her  sufferings,  it  will  abbreviate 
them.  A  full  bladder  must  be  emptied  with  the  catheter.  Tym- 
panites may  perhaps  be  overcome  wdth  a  rectal  tube  or  an  ox-gall 
enema.  If  there  is  a  superabundance  of  liquor  amnii,  it  may  be 
necessary  to  give  some  of  it  an  outlet  by  rupturing  the  membranes. 
A  pendulous  or  weak  abdomen  may  be  lifted  or  strengthened  by 
surrounding  it  with  a  sheet  upon  the  ends  of  which  assistants  pull 
so  as  to  compress  the  abdominal  wall.  The  uterus  may  be  seized 
between  the  receding  recti  muscles  and  direct  pressure  exercised  with 
the  hands  of  the  accoucheur.  But  if  labor  is  arrested,  artificial  deliv- 
ery by  means  of  the  forceps  or  version  becomes  necessary. 

If  a  subcutaneous  emphysema  develops,  we  must  stop  all  use  of 
the  abdominal  pressure  and  deliver. 

If  the  patient  abuses  the  abdominal  pressure,  we  must  deprive  her 
of  all  support  for  arms  and  legs  and  place  her  on  the  left  side.  If 
the  contractions  continue  to  be  strong,  they  should  be  checked  by  the 
administration  of  chloroform.  But  if  there  is  any  obstacle  to  be  over- 
come, we  must  remember  that  both  strong  uterine  and  abdominal 
contractions  are  nature's  own  remedy  and  not  interfere  with  her 
work,  unless  there  arise  special  indications  for  so  doing. 


CHAPTER   III. 

UNFAVORABLE    POSITION,    PRESENTATION,    OR    ATTITUDE    OF    FCETUS. 

The  advantages  of  the  occipito-anterior  position  of  the  vertex 
presentation  are  so  great  that  every  deviation  from  this  position  and 
presentation  must  be  looked  upon  as  abnormal.  In  this  category  we 
have  to  consider  the  occipitoposterior  position ;  the  occipitolateral 
position ;  the  lateral  obliquity  of  the  head ;  face,  brow,  pelvic,  and 
cross  presentations. 

§  1.  Occipitoposterior  Positions. — Occipitoposterior  positions  in 
vertex  presentation  are  those  in  which  the  small  fontanelle  points 
respectively  to  the  right  or  left  sacro-iliac  joint.  The  former  is  called 
the  third  or  R.  0.  P.  position,  the  latter  the  fourth  or  L.  0.  P.  position. 
They  may  be  primary  or  secondary, — that  is  to  say,  the  occiput  may 
from  the  beginning  of  labor  point  backward  towards  the  sacro-iliac 
joint,  or  it  may  at  first  point  forward  in  the  direction  of  the  iliopec- 
tineal  eminence,  and  during  the  progress  of  labor  turn  backward. 
The  latter  is  a  rare  occurrence.  The  occipitoposterior  position  is 
chiefly  found  when  the  child  is  small  or  the  pelvis  large  or  flat,  in 
twin  pregnancies,  or  with  prolapse  of  the  arm  in  front  of  the  head. 


UNFAVORABLE    POSITION    OF    F(ETUS. 


363 


In  most  cases  nature  herself  remedies  the  abnormal  position.  The 
head  is  strongly  flexed  against  the  sternum,  so  that  the  part  sur- 
rounding the  small  fontanelle  strikes  the  pelvic  floor  first  and  by  the 
resistance  it  meets  here  is  turned  forward,  Avhile  the  forehead  is  so  high 
up  that  the  anterior  wall  of  the  pelvis  has  no  influence  on  it.  The 
occiput  has  to  follow  the  whole  posterior  wall  of  the  pelvis,  which  is 
much  longer  than  the  anterior,  the  configuration  of  the  head  does  not 


Mechanism  of  labor  in  persistent  oceipitoposterior  positions.     (Tarnier  and  Budin,  1.  c.) 


fit  that  of  the  pelvis,  and  in  turning  forward  the  occiput  has  to  tra- 
verse about  one-third  of  the  pelvic  circumference.  Labor  is,  therefore, 
always  more  painful  and  protracted,  but  may  end  without  interference 
on  the  part  of  the  accoucheur,  the  third  position  being  converted  into 
the  second  and  the  fourth  into  the  first. 

If  the  favorable  flexion  fails  to  take  place,  and  the  head  on  the 
contrary  becomes  more  extended,  the  large  fontanelle  dips  low  down 


364 


ABNORMAL   LABOR. 


in  front  and  the  sinciput  is  arrested  at  the  pubic  arch,  a  broad  frontal 
protuberance  being  jammed  against  it,  instead  of  as  in  normal  labor 
the  occiput  slipping  out  under  and  in  front  of  it.  The  head  has  to  pass 
with  a  very  large  circumference,  distending  the  perineum  enormously, 
until  the  occiput  gets  free  from  its  edge.  Then  an  extension  takes 
place,  allowing  the  forehead  and  face  to  roll  out  under  the  pubic  arch, 
and,  finally,  the  body  is  born  (Fig.  279). 

In  consequence  of  the  great  pressure  the  forehead  sustains  in 
passing  under  the  pubic  arch,  the  head  of  the  child  becomes  much 
elongated  in  the  mento-occipital  diameter,  and  gets  a  peculiar  shape 
suggestive  of  a  loaf  of  sugar  (Fig.  280),  which  becomes  particularly 


Fig.  280. 


Fig.  281. 


Shape  of  head  of  child  born  in  persistent  occipito- 
posterior  position.     (Tarnier  and  Budin,  1.  c.) 


Shape  of  head  of  child  born  in  occipito-anterior 
position,  vertex  presentation. 


evident  by  comparison  with  Fig.  281,  representing  the  shape  of  a 
head  born  in  occipito-anterior  position,  vertex  presentation. 

Diagnosis. — The  accoucheur  arrives  at  the  conclusion  that  he  has 
to  deal  with  an  occipitoposterior  position  in  the  following  way.  By 
abdominal  palpation  he  may  feel  the  back  of  the  foetus  turned  back- 
ward in  the  mother's  flank  and  the  small  parts  turned  forward  in  the 
opposite  side.  The  fetal  heart  sound  is  heard  under  the  level  of  the 
umbilicus  farther  out  to  the  side  than  when  the  back  is  turned  for- 
ward. But  absolute  certainty  is  reached  only  when  he  feels  the 
posterior  fontanelle  pointing  back  in  the  direction  of  the  sacro-iliac 
articulation  or  feels  the  anterior  fontanelle  pointing  forward  toward 
the  anterior  wall  of  the  pelvis. 

Treatment. — By  pressing  on  the  forehead  of  the  foetus  with  two 
fingers  the  accoucheur  should  strive  to  bring  about  the  favorable 
flexure.  With  this  he  may  combine  pressure  on  the  pubic  side  of 
the  forehead,  so  as  to  facilitate  its  rotation  backward. 


.  UNFAVORABLE   POSITION   OF   FCETUS.  365 

If  he  does  not  succeed  in  this  manoeuvre,  he  should  wait  patiently 
so  as  to  let  the  head  come  well  down,  since  too  early  a  use  of  the  for- 
ceps is  apt  to  be  attended  by  great  injury  to  the  mother.  He  must 
especially  beware  of  trying  to  correct  the  position  by  rotating  the  head 
with  the  forceps  while  it  is  still  high  up  in  the  pelvis.  He  should 
first  simply  pull  downward  until  the  head  reaches  the  pelvic  floor. 
Then  he  may  cautiously  try  to  rotate  the  head  with  the  forceps. 
Sometimes  the  rotation  takes  place  spontaneously  and  carries  the 
forceps  along.  As  the  convexity  of  the  pelvic  curvature  would  be 
rotated  forward  and  would  injure  the  soft  parts  of  the  mother,  the 
instrument  should  be  removed,  and  the  rotation  should  be  left  to 
nature  or  finished  manually.  If  necessary,  the  forceps  may  be  reap- 
plied for  extracting  the  head  after  rotation  has  taken  place. 

But  sometimes  no  rotation  can  be  accomplished.  Then  delivery 
is  brought  about  by  means  of  the  forceps,  the  occiput  remaining  back- 
ward. In  the  beginning  the  direction  of  the  pull  should  be  more 
forward  than  in  occipito-anterior  positions  ;  but  when  the  occiput  has 
passed  the  perineum,  the  direction  should  be  reversed,  so  as  to  help 
the  forehead  out  and  protect  the  nose  from  injury  by  pressure  against 
the  pubic  arch. 

§  2.  Occipitolateral  Position. — This  abnormality  has  received 
so  little  attention  by  American  and  English  accoucheurs  that  it  has 
no  name.  It  is,  however,  not  very  rare,  and  it  may  offer  a  serious 
impediment  to  delivery,  I  refer  to  the  condition  characterized  by 
the  occiput  failing  to  rotate  forward,  and  the  head  descending  with 
its  occipitofrontal  diameter  through  the  transverse  diameter  of  the 
pelvis. 

Primiparae,  in  whom  the  head  normally  engages  in  the  pelvic 
cavity  during  pregnancy  in  the  transverse  diameter,  are  predisposed 
to  this  anomaly.  It  is  apt  to  occur  in  the  justo-major  pelvis,  in  the 
flat  rhachitic  pelvis  with  large  pelvic  cavity,  in  a  pelvis  Avith  insuffi- 
cient inclination,  or  in  cases  of  prolapse  of  an  arm  between  the  head 
and  the  anterior  pelvic  wall. 

Sometimes  the  normal  rotation  forward  of  the  occiput  takes  place 
late  in  labor,  and  then  everything  becomes  normal.  In  other  cases 
the  occiput,  on  the  contrary,  turns  backward  into  the  hollow  of  the 
sacrum.  Rarely  the  head  can  be  born  in  the  transverse  diameter  of 
the  pelvis. 

Diagnosis. — The  posterior  fontanelle  is  found  in  one  side.  Some- 
times the  anterior  fontanelle  may  be  felt  in  the  opposite  side.  The 
sagittal  suture  lies  in  the  transverse  diameter  of  the  pelvis. 

Treatment. — Sometimes  the  position  may  be  corrected  by  placing 
the  patient  on  the  side  towards  which  the  occiput  points  and  placing 
a  hard  pillow  under  her  flank.     In  other  cases  the  desired  rotation  is 


366  ABNORMAL   LABOR. 

obtained  by  having  the  patient  occupy  a  half-sitting  posture  and  bear 
down  strongly,  using  special  supports  for  arms  and  legs,  as  described 
on  page  191  with  Fig,  222. 

We  may  try  by  digital  pressure  on  the  posterior  parietal  bone, 
near  the  occiput,  to  move  this  forward.  This  may  be  done  more 
effectively  by  using  a  vectis  or  one  blade  of  a  forceps.  In  most  cases 
extraction  by  means  of  the  forceps  becomes  necessary,  and  as  the 
position  of  the  head  is  unfavorable  for  its  application  in  the  sides  of 
the  pelvis,  it  should  be  applied  as  nearly  as  circumstances  permit  to 
the  sides  of  the  head,  favoring  the  forward  rotation. 

§  3.  Lateral  Obliquity  of  the  Head. — We  have  seen  that  nor- 
mally in  the  beginning  of  labor  the  sagittal  suture  often  is  placed 
nearer  to  the  promontory  than  to  the  symphysis  pubis.  This  lateral 
obliquity  of  the  head  against  the  posterior  shoulder  may  become  so 
marked  that  it  constitutes  a  hinderance  to  the  progress  of  labor.  The 
sagittal  suture  is  then  found  running  transversely  quite  near  the  pro- 
montory, and  the  brim  of  the  pelvis  is  occupied  by  the  anterior  parietal 
bone — anterior  parietal  presentation.  This  condition  is  chiefly  caused 
by  a  pendulous  abdomen,  and  is  therefore  more  common  in  pluriparae. 

But  the  head  may  also,  although  more  rarely,  be  bent  against  the 
anterior  shoulder,  in  which  case  the  sagittal  suture  is  placed  trans- 
versely, close  to  or  above  the  anterior  pelvic  wall,  and  the  posterior 
bregmatic  bone  fills  the  superior  strait  of  the  pelvis.  This  is  called 
posterior  parietal  presentation. 

The  head  may  be  bent  so  much  towards  one  of  the  shoulders 
that  the  ear  presents,  and  then  the  situation  may  be  designated 
as  an  anterior  ov  posterior  ear  presentation.^  These  presentations  are 
very  rare  in  normal  pelves.  As  a  rule,  they  occur  only  in  narrow 
pelves. 

When  the  head  is  much  bent  to  the  side,  neither  the  sagittal 
suture  nor  any  of  the  adjoining  fontanelles  may  be  felt.  The  fonta- 
nelle  felt  is  the  posterior  side  fontanelle,  which  gives  a  sensation  very 
similar  to  that  perceived  while  touching  the  upper  posterior  fontanelle, 
three  sutures  meeting  to  form  either  of  them.  At  the  superior  pos- 
terior fontanelle  we  have  the  sagittal  and  the  two  branches  of  the 
lambdoid  suture  ;  at  the  posterior  side  fontanelle  it  is  the  lambdoid 
joining  the  mastoparietal  and  the  masto-occipital.  But  they  may  be 
distinguished  by  the  adjoining  bone.  Following  the  sagittal  suture, 
we  meet  the  entirely  smooth,  evenly  convex  upper  end  of  the  occipi- 
tal bone,  while  when  we  follow  the  lambdoid  downward  we  come  to 
the  mastoid  portion  of  the  temporal  bone,  Avhich  presents  rugosities 
formed  by  bony  ridges  and  protuberances. 

In  making  a  full  vaginal  examination  the  accoucheur  may  come 

1  Garrigues,  "Ear  Presentations,"  Amer.  Jour.  Med.  Sci.,  June,  1890. 


UNFAVORABLE    PRESENTATION    OF   FCETUS.  367 

within  reach  of  the  fetal  eye,  which  may  suffer  injury  unless  he 
proceeds  with  due  gentleness. 

In  most  cases  the  prognosis  is  favorable,  as  the  head  either  changes 
its  relations  to  the  body  under  influence  of  labor-pains  or  can  be 
manually  replaced  by  the  accoucheur.  But  if  the  abnormal  attitude 
continues  after  the  waters  have  broken,  the  condition  is  a  serious  one, 
as  the  head  cannot  pass  through  the  pelvis  when  so  placed. 

Treatment. — Before  the  membranes  have  ruptured,  the  presenta- 
tion may  be  corrected  by  placing  the  woman  on  the  side  where  the 
occiput  is,  pushing  the  fetal  body  over  to  the  same  side,  and  pressing 
the  anterior  portion  of  the  presenting  parietal  bone  upward.  Thus 
the  posterior  superior  fontanelle  is  brought  downward  and  forward, 
and  to  keep  it  there  the  patient  should  remain  in  the  lateral  posture. 
In  other  eases  it  may  be  necessary  to  insert  the  whole  hand  and  cor- 
rect the  malposition.  In  others,  again,  podalic  version  is  resorted  to. 
By  this  operation  the  foetus  is  seized  by  one  or  both  lower  extremities 
and  turned  so  as  to  be  born  with  these  foremost.  (See  Operations.) 
Even  craniotomy  has  been  performed,  and  those  who  are  opposed  to 
this  procedure  when  the  child  is  alive  will  have  to  substitute  sym- 
physeotomy. Craniotomy  is  an  operation  by  which  the  size  of  the 
head  of  the  foetus  is  diminished  by  giving  exit  to  part  of  the  brain. 
In  symphyseotomy  the  symphysis  pubis  is  cut  in  order  to  enlarge  the 
pelvis.     (See  Operations.) 

§  4.  Face  Presentation. — Frequency. — There  is  a  remarkable  dif- 
ference in  the  frequency  with  which  face  presentations  occur  in  the 
statistics  of  different  lying-in  asylums.  While  in  the  great  Rotunda 
Hospital  of  Dublin  it  was  observed  only  once  in  497  cases  of  labor,  in 
the  Paris  Maternity  it  occurred  once  in  every  250  cases,  and  in  German 
clinics  even  once  in  169  cases.  The  discrepancy  is  so  great  that  it 
hardly  can  be  accidental.  English  obstetricians  have  thought  to  find 
the  explanation  in  their  systematic  use  of  the  left-side  position  ;  but  in 
the  New  York  Maternity  Hospital,  where  the  patient  is  allowed  to  lie 
as  she  likes  during  the  earlier  stages,  and  where  most  accoucheurs 
deliver  the  women  lying  on  their  backs,  face  presentations  are  still 
rarer  than  in  the  Rotunda.  It  is,  in  the  opinion  of  the  writer,  much 
more  likely  that  the  comparative  frequency  of  face  presentations  on 
the  continent  of  Europe  is  due  to  the  greater  frequency  of  abnormal 
pelves. 

Etiology. — Face  presentation  is  found  oftener  in  primiparae  than 
in  multiparae,  which  probably  is  due  to  the  greater  resistance  of  the 
lower  uterine  segment.  It  is  more  frequent  when  the  back  of  the 
foetus  is  turned  to  the  right  than  when  it  is  turned  to  the  left.  The 
explanation  of  this  fact  is  probably  to  be  found  in  tlie  much  more 
common  occurrence  of  a  version  of  the  uterus  to  the  right  than  to 


368 


ABNORMAL   LABOR. 


the  left.  When  the  breech  of  the  child  falls  far  over  to  the  right  side 
and  the  forehead  hitches  on  the  pelvic  brim,  there  results  a  face  pres- 
entation (Fig.  282),  and  the  occiput  is  found  in  the  side  towards 
which  the  uterus  is  inclined. 

If  the  occiput  is  unusually  prominent,  it  is  apt  to  be  arrested  at  the 
pelvic  brim,  when  the  forehead  and  the  face  will  be  pushed  down  by 

pressure  from  above  by  the  con- 
Fir   '?S2 

'■  "    ■  tracting  uterus. 

The  chin  of  a  fat  baby  can- 
not be  pressed  so  far  against  the 
sternum  as  that  of  a  lean  one, 
and  consequently  it  may  become 
farther  and  farther  removed  from 
the  sternum  during  the  progress 
of  labor.  Face  presentation  may 
also  be  due  to  a  congenital  goitre 
preventing  the  approximation  of 
the  chin  to  the  sternum. 

Monsters  called  hemicephali, 
in  whom  the  cranium  is  missing 
(Fig,  319),  present  usually  with 
the  face.  Any  obstruction  in  the 
genital  canal,  especially  a  shortness 
of  the  transverse  diameter,  may 
lead  to  face  presentation. 
In  rare  cases  the  face  presentation  may  be  found  before  labor  begins, 
but  it  is  nearly  always  produced  during  and  by  labor,  a  vertex  presenta- 
tion being  changed  by  extension  into  a  face  presentation.  The  face  is 
mostly  found  with  its  mentofrontal  diameter  in  the  transverse  or  the 
oblique  diameter  of  the  pelvis.  We  may  distinguish  four  positions, 
corresponding  to  the  four  vertex  presentations  from  which  they  have 
been  formed,  the  forehead  occupying  the  place  of  the  occiput. 

In  the  first  position  the  forehead  is  turned  towards  the  left  iliopecti- 
neal  eminence,  or  lower  down  in  the  pelvis  to  the  left  foramen  ovale, 
while  the  chin  points  towards  the  right  iliosacral  articulation. 

In  the  second  position  the  forehead  lies  against  the  right  iliopec- 
tineal  eminence  or  foramen  ovale  and  the  chin  is  at  the  left  iliosacral 
joint. 

In  the  third  position  the  forehead  is  at  the  right  iliosacral  articula- 
tion and  the  chin  forward  to  the  left  pubic  bone  (Fig.  107,  p.  77). 

In  the  fourth  position  the  forehead  is  found  at  the  left  sacro-iliac 
articulation  and  the  chin  forward  to  the  right  pubic  bone. 

Mechanism  of  Labor  in  Face  Presentation. — In  most  cases  the 
delivery  may  be  accomplished  by  nature's  sole  efforts.     Suppose  we 


Face  presentation  due  to  lateroversion  of  the 
uterus.     (Ahlfeld.) 


UNFAVORABLE   PRESENTATION   OF    F(ETUS. 


369 


have  the  face  in  the  first  position  (Fig.  283),  When  labor  begins,  the 
forehead  is  lower  down  than  the  cliin.  Then  an  extension  takes  place 
which  allows  the  chin  to  come  lower  down — descent.  This  extension 
is  brought  about  by  the  head  forming  a  two-armed  lever.  That  branch 
which  is  formed  by  the  tissues  situate  between  the  foramen  magnum 
and  the  occiput,  being  longer  than  the  distance  from  the  foramen  mag- 
num to  the  chin,  is  kept  back  by  the  greater  resistance  which  it  meets 
with,  while  the  shorter  branch  descends  under  the  pressure  from  above,- 
which  centres  in  the  spinal  cord  articulating  with  the  head.     Next  a 

Fig.  283. 


Face  presentation,  extension  and  descent.     (Tarnier  and  Chantreuil,  1.  c. 


rotation  takes  place,  by  which  the  chin  is  turned  forward  towards  the 
pubic  arch.  This  rotation  is  brought  about  in  the  same  way  as  that 
of  the  occiput  moving  forward  in  normal  labors, — namely,  by  pressure 
against  the  pelvic  floor,  especially  the  strong  sacrosciatic  ligaments. 
The  anterior  cheek — in  the  first  position  the  right — descends  a  little 
ahead  of  the  posterior.  The  anterior  angle  of  the  mouth  appears  first 
in  the  vulva,  followed  by  the  chin — in  the  first  position  under  the  right 
branch  of  the  pubic  arch.  When  the  chin  gets  clear  of  the  arch,  a 
.flexion  (Fig.  284)  takes  place,  the  chin  being  pushed  up  in  front  of  the 

24 


370 


ABNORMAL   LABOR. 


symphysis  pubis  until  the  neck  presses  against  the  arch  and  the  nose, 
eyes,  forehead,  and  vertex  rolKng  over  the  perineum. 

When  the  head  is  born,  an  external  rotation  takes  place  just  as  in 
vertex  presentation  and  for  the  same  reason,  the  shoulders  going 
through  a  rotation  similar  to  that  to  which  the  head  was  subjected.  By 
this  external  rotation  the  chin  is  moved  in  the  direction  wdiich  it  came 
from. 

In  the  second  position  the  mechanism  is  exactly  the  same,  with  the 
exception  that  the  forehead  at  first  points  to  the  right  instead  of  the 

Fig.  284. 


Face  presentation,  rotation  and  flexion.     (Tarnier  and  Chantreuil,  1.  c. 


left,  and  the  chin  rotates  forward  in  the  left  side  of  the  pelvis.  In  the 
third  and  fourth  positions  the  chin  is  already  turned  forward  from  the 
beginning,  and  the  internal  rotation  is  therefore  much  less  marked. 

Diagnosis. — By  external  palpation  the  occiput  is  felt  above  the 
superior  strait  and  between  the  skull  and  the  back  is  felt  a  deep 
hollow.  The  heart-sounds  are  heard  more  distinctly  through  the 
chest  of  the  foetus  pressing  against  the  uterine  wall  than  through  the 
remote  back.  In  the  beginning  the  diagnosis  of  face  presentations  by 
means  of  vaginal  examination  may  be  difficult,  the  examining  finger 
impinging  on  the  forehead,  which  may  be  mistaken  for  the  vertex. 
Later  the  diagnosis  becomes  very  easy.  We  then  feel  the  forehead, 
the  orbits  with  the  eyes,  the  nose  with  the  nostrils,  the  mouth  with 


UNFAVORABLE    PRESENTATION    OF    FCETUS. 


371 


the  hard  alveolar  ridges,  and  the  chin.  When  the  face  becomes  much 
swollen,  it  may,  however,  be  mistaken  for  the  breech,  the  cheeks  being 
taken  for  the  nates,  the  nose  for  the  genitals,  and  the  mouth  for  the 
anus  (Fig.  285) ;  but  the  diagnosis  can  always  be  made  by  the  pres- 
ence of  the  alveolar  ridges  inside  of  the  mouth,  to  which  nothing 
corresponds  in  the  rectum,  and  the  hard  orbital  edges  surrounding  the 
soft  globular  eyes. 

In  palpating  the  nose  attention  should  be  paid  to  the  direction  of 

Fig.  285. 


Face  presentation  in  distended  vulva,     i  Ahliclil.  j 

the  nostrils,  as  they  point  in  the  direction  of  the  chin,  the  position  of 
which  is  of  so  great  importance. 

Persistent  Mentoposterior  Position. — Sometimes  the  chin  does  not 
rotate  forward  until  the  face  has  descended  so  low  down  that  it  presses 
on  the  pelvic  floor.  In  rare  cases  it  does  not  rotate  forward  at  all, 
and  then  we  have  to  deal  with  one  of  the  most  difficult  situations  in 
obstetrics.  Rarely  nature  alone  can  end  labor  under  these  circum- 
stances, and  it  is  only  possible  if  the  head  is  exceptionally  small  or 
the  pelvis  exceptionally  large,  since  the  occiput  and  the  chest  have  to 
pass  at  once  through  the  pelvis  (Fig.  286).  If  the  child  is  born  in  this 
position  the  forehead  and  the  large  fontanelle  come  into  view  under 
the  pubic  arch.  This  part  of  the  skull  is  pressed  tightly  against  the 
arch,  and  the  face  rolls  over  the  perineum  until  tlie  chin  gets  free 


372 


ABNORMAL   LABOR. 


of  its  edge,  and  the  occiput  comes  down  in  front.  More  rarely  the 
forehead  is  pressed  against  the  anterior  wall  of  the  pelvis,  the  eyes  and 
the  nose  become  ^dsible,  the  mouth  and  chin  roll  over  the  perineum, 
and  finally  the  forehead,  vertex,  and  occiput  get  clear  of  the  pubic 
arch.  In  cases  of  persistent  mentoposterior  positions  the  mentofrontal 
diameter  descends  through  the  oblique  diameter  of  the  outlet,  the  soft 
parts  at  the  sacrosciatic  notch  yielding  a  cjuarter  of  an  inch. 

Prognosis. — For  the  mother  the  prognosis  in  face  presentations  is 
fairly  good,  but  the  labor  is,  as  a  rule,  protracted  and  painful.  Uterine 
inertia  may  set  in  and  the  patient  become  exhausted.     For  the  child 

Fig.  286. 


Persistent  mentoposterior  position. 


the  danger  is  much  more  serious.  "While  the  infantile  mortality  in 
vertex  presentation  is  only  5  per  cent.,  in  face  presentations  it  reaches 
13  per  cent.  In  persistent  mentoposterior  positions  there  is  hardly 
any  chance  of  delivering  a  living  child.  The  cause  of  this  great  mor- 
tality is  to  be  sought  in  the  compression  of  the  jugular  veins  of  the 
neck  and  the  consequent  congestion  of  the  brain.  The  third  and 
fourth  positions  are  comparatively  favorable,  because  in  them  the  chin 
is  turned  forward  from  the  beginning. 

Effect  on  the  Shape  of  the  Child. — The  serosanguineous  swelling 
known  as  caput  succedaneum  (Fig.  216.  p.  178)  begins  in  face  presenta- 
tions at  the  anterior  angle  of  the  mouth  and  extends  over  the  cheek, 
the  m.alar  bone,  and  may  even  pass  over  on  the  other  half  of  the  face. 
It  has  a  dark-blue  color  and  is  so  disfiguring  that  the  accoucheur 
should  prepare  the  bystanders  for  it,  and  should  not  let  the  mother 


UNFAVORABLE    PRESEXTATIOX    OF    F(ETUS. 


373 


Fig.  287. 


see  the  child  until  the  swelling  has  subsided,  which  it  does  in  the 
course  of  a  few  days. 

The  skull  becomes  much  compressed  in  its  perpendicular  diam- 
eters, and  the  occiput  much  elongated  (Fig.  287). 

This  peculiar  conformation  also,  as 
a  rule,  chsappears  in  a  few  days,  but 
may  last  for  weeks,  and  perhaps  even 
cause  a  permanent  dolichocephalia. 

After  difficult  deliveries  in  face  pres- 
entation the  whole  body  of  the  child 
may  for  days  have  a  peculiar  opisthot- 
onic  shape.  Howsoever  the  child  is 
placed,   it   extends    its    occiput   against 

Fig.  288. 


Shape  of  skull  of  child  born  in  face 
presentation.    (Charpentier.) 


Attitude  of  child  born  in  face  presentation. 
( Olshausen-Veit. ) 


the  back  and  brings  the  lower  part  of  the  body  up  against  the  head 
(Fig.  288). 

Treatment. — Since  in  the  great  majority  of  cases  nature  can  finish 
labor,  and  the  accoucheur  risks  to  do  more  harm  than  good,  he  should, 
if  the  case  is  seen  early  and  the  dimensions  of  the  child  and  the  pelvis 
are  satisfactory,  first  of  all  await  developments.  If  the  pelvis  is  flat, 
he  had  better  resort  to  podalic  version  and  extraction  as  soon  as  the 
OS  is  fully  dilated  and  before  the  head  becomes  impacted.  If  the 
pelvis  is  generally  contracted,  the  face  presentation  should  early  be 
changed  to  a  vertex  presentation. 

If  after  the  rupture  of  the  membranes  labor  does  not  progress 
favorably,  an  attempt  should  likewise  be  made  to  change  the  face 
presentation  into  a  vertex  presentation  by  Thomas  method,  which 
simultaneously  attacks  the  head  and  the  body  of  the  foetus  by  internal 
and  external  manipulations.  For  this  purpose  the  patient  is  placed 
on  the  side  on  which  the  chin  is.  Pressure  is  exerted  upward  on  the 
hard  parts  of  the  face  with  a  view  of  chslodging  the  chin  upward. 
The  occiput  is  pulled  down  manually.     With  the  other  hand  pressure 


374 


ABNORMAL   LABOR. 


Fig.  289. 


is  made  on  the  bulging  cliest,  and  simultaneously  the  breech  is  pushed 
forward  and  to  the  opposite  side  (Fig.  289). 

Version  may  also  be  resorted  to  at  any  time  when  the  condition 
of  the  mother  or  the  child  is  such  that  a  speedy  delivery  becomes 
necessary,  or  in  cases  of  persistent  mentoposterior  position  ;  and  to 

be  of  any  use,  it  must 
be  performed  before  the 
head  is  so  impacted  that 
it  cannot  be  moved. 

The  forceps  may  be 
used  late  in  labor  when 
the  chin  is  rotated  under 
the  pubic  arch,  and  then 
traction  should  be  made 
downward  and  forward, 
so  as  to  drag  the  occiput 
over  the  perineum. 

If  the  chin  remains  be- 
hind, a  cautious  attempt 
may  be  made  to  turn  it 
forward  by  inserting  a 
finger  into  the  mouth  or 
by  pressing  on  the  side  of 
the  forehead  ;  or  we  may 
try  to  rotate  the  head  by 
means  of  the  forceps,  pref- 
erably a  straight  one,  as 
this  moves  more  freely  in 
the  pelvis  than  the  curved 
one.  If  in  spite  of  all 
efforts  the  chin  remains 
behind,  we  may  try  to  de- 
liver the  head  in  this  di- 
rection by  pulling  the  chin 
over  the  perineum.  If  that  also  proves  impossible,  craniotomy  should 
be  performed.  Even  if  the  child  is  still  alive,  we  know  that  it  is 
doomed,  and  may  therefore  without  hesitation  sacrifice  it  in  the 
interest  of  the  mother.  The  perforation  may  be  made  through  an 
orbit  or  the  hard  palate. 

§  5.  Brow  Presentation. — Sometimes  the  extension  by  which  a 
vertex  presentation  is  changed  into  a  face  presentation  is  arrested  half- 
way, the  result  being  that  the  forehead  presents  itself  at  the  superior 
strait.  This  is  a  still  worse  presentation  than  a  face  presentation,  for 
if  the  head  should  go  down  in  this  position  it  would  have  to  pass 


Thorn's  method  of  changing  a  face  into  a  vertex  presen- 
tation. The  arrows  a  a  show  how  pressure  is  made  from  the 
vagina  against  the  chin,  the  malar  bones,  and  the  forehead 
and  the  occiput  is  pulled  down ;  6  shows  the  direction  of 
pressure  against  the  chest ;  c  shows  the  direction  in  which 
the  breech  is  moved. 


UNFAVORABLE  PRESENTATION    OF   F(ETUS. 


375 


Fig.  290. 


the  pelvis  with  the  long  occipitomental  diameter,  which  is  longer  than 
the  pelvic  diameters. 

Mechanism  of  Labor. — In  the  beginning  the  frontal  suture  lies  in 
the  transverse  diameter  of  the  pelvis.  During  the  progress  of  labor 
the  forehead,  as  a  rule,  turns  forward  and  the  occiput  backward. 
The  superior  maxillary  bone  is  pressed  against  the  pubic  arch.  In 
the  vulva  appears  first  the  forehead,  then  the  eyes,  and  thereafter  the 
vertex  and  occiput  roll  over  the  perineum.  Last  of  all  the  superior 
maxilla,  the  mouth,  and  the  chin  emerge  under  the  pubic  arch. 

But  in  some  cases  this  rotation  forward  of  the  forehead  does  not 
take  place,  the  head  remaining  in  the  trans- 
verse diameter.  In  such  cases  the  face,  ex- 
cept the  lower  jaw,  appears  under  one  side 
of  the  pubic  arch,  and  the  occiput  under  the 
other,  and  at  last  the  lower  jaw  is  born. 

Diagnosis. — The  diagnosis  is  easy.  The 
examining  finger  feels  the  forehead  occupying 
the  brim,  the  large  fontanelle  on  one  side  and 
the  bridge  of  the  nose  and  one  orbit  at  the 
other. 

Prognosis. — The  prognosis  for  the  mother 
is  in  so  far  serious  as  the  labor  is  very  tedious, 
her  strength  may  give  out  or  operations  be- 
come necessary  to  deliver  her.  For  the  child 
it  is  much  worse,  half  of  the  children  being 
lost. 

The  Shape  of  the  Child's  Head. — The  caput 
succedaneum  forms  on  the  brow,  and  the 
skull  itself  is  drawn  out  in  this  direction  and 
in  that  of  the  occiput,  whereas  it  is  com- 
pressed in  the  mentobregmatic  diameter  (Fig. 
290). 

Treatment. — Childbirth  in  brow  presenta- 
tion being  beset  with  such  grave  difficulties, 
the  treatment  must  be  an  active  one.  In  the  beginning  of  labor  we 
may  by  pressure  on  the  presenting  part  try  to  change  the  brow  pres- 
entation into  a  vertex  presentation,  which  often  is  possible.  The 
next  best  thing  is  to  change  it  by  similar  means  into  a  face  presen- 
tation. If  neither  of  these  attempts  succeed  and  the  soft  parts  are 
sufficiently  dilated,  it  is  best  to  perform  podalic  version.  If  the  head 
is  too  low  down  for  that,  we  may  apply  the  forceps  and  pull  well 
down  at  first  until  the  superior  maxilla  touches  the  pubic  arch.  Then 
we  reverse  the  direction  and  pull  forward  in  order  to  make  the  vertex 
roll  over  the  perineum. 


Head  of  child  born  in  brow  pres- 
entation.    (Charpentier.) 


376  ABNORMAL   LABOR. 

If  we  again  fail,  nothing  is  left  but  craniotomy.  To  this  we  have 
recourse  as  soon  as  the  child  dies,  but  even  when  it  is  living  the 
operation  is  indicated,  since  the  child  is  lost  anyhow  and  the  mother 
must  be  delivered.  Those  who  are  absolutely  opposed  to  sacrificing 
fetal  life  might  in  brow  presentations  and  bad  face  presentations  try 
symphyseotomy.  It  is  not  unlikely  that  the  gain  in  room,  which 
sometimes  is  quite  considerable,  would  allow  a  correction  of  the 
position  or  give  better  chances  for  the  forceps  operation. 

§  6.  Pelvic  Presentation. — When  any  part  of  the  lower  extremi- 
ties of  the  foetus  presents  itself  at  the  superior  strait  of  the  pelvis, 
it  is  called  a  pelvic  presentation.  The  breech  alone  may  be  found 
at  the  entrance  to  the  pelvic  cavity  (Fig.  108,  p.  78)  or  the  breech 
together  Avith  one  or  both  feet.  This  is  called  a  breech  presentation. 
Or  one  or  both  feet  alone  may  occupy  the  lower  pole  of  the  ovum» 
which  is  called  a  foot  presentation  or  footling  presentation  (Fig.  110, 
p.  80).  Or  one  or  both  knees  may  be  there  instead  (Fig.  109,  p.  79), 
a  knee  presentation.  The  latter  is  extremely  rare,  and  we  can  realize 
that  it  must  be  so,  when  we  see  how  the  foetus  has  to  undergo  partial 
extension  and  the  uterus  becomes  much  stretched. 

Frequency. — As  pelvic-end  presentations  are  likely  to  give  some 
trouble,  they  have  a  tendency  to  gravitate  towards  lying-in  asylums,  in 
which  they  occur  in  about  three  per  cent,  of  labors,  while  in  private 
practice  they  are  not  more  than  about  one-half  as  common. 

Positions. — In  pelvic-end  presentations  we  may  distinguish  four 
positions,  corresponding  to  the  four  vertex  positions,  the  sacrum  occu- 
pying the  place  of  the  occiput. 

In  the  first  position,  or  left  sacro-anterior  position,  L.  S.  A.,  the 
sacrum  is  turned  forward  to  the  left  in  the  direction  of  the  iliopec- 
tineal  eminence  or  the  foramen  ovale. 

In  the  second  position,  the  right  sacro-anterior  position,  R.  S.  A.,  the 
sacrum  is  turned  to  the  right  iliopectineal  eminence  or  foramen  ovale. 

In  the  third  position,  or  right  sacroposterior  position,  R.  S.  P.,  the 
sacrum  of  the  foetus  is  found  in  front  of  the  right  iliosacral  joint  of  the 
mother. 

In  the  fourth  position,  the  left  sacroposterior  position,  L.  S.  P.,  the 
fetal  sacrum  is  found  at  the  left  iliosacral  articulation. 

Of  these  positions  the  first  and  third  are  the  most  common,  for  the 
same  reasons  that  the  head  in  vertex  presentation  usually  occupies  the 
left  oblique  diameter.  Rut  in  the  course  of  labor  the  sacrum  nearly 
always  turns  forward,  so  that  labor  ends  in  the  first  or  the  second 
position. 

If  breech  and  feet  are  together,  they  form  so  broad  a  base  that 
they  stay  above  the  brim  and  no  engagement  takes  place  during 
pregnancy. 


UNFAVORABLE  PRESENTATION    OF   F(ETUS. 


377 


Etiology. — During  pregnancy  the  presentation  of  the  foetus  changes 
quite  frequently,  and,  since  at  the  same  time  the  foetus  grows,  it  may, 
so  to  say,  be  caught  while  the  breech  is  turned  down,  and  become  too 
large  for  a  return  to  the  vertex  presentation.  Some  women  will  have 
a  pelvic  presentation  in  every  pregnancy,  which  seems  to  prove  that 
there  is  some  peculiarity  in  the  shape  of  their  uterus  which  favors  this 
presentation.  It  is  more  common  in  multiparous  women  than  in  pri- 
miparous,  probably  on  account  of  a  less  perfect  shape  of  the  uterus. 
It  is  also  more  frequent  in  twin  pregnancies,  which  is  explained  by 
the  necessity  of  one  child  adapting  itself  to  the  other. 

Mechanism  of  Labo7\ — When  labor  begins,  we  first  have  a  descent 
with  the  transverse  diameter  of  the  breech  in  the  oblique  diameter  of 

Fig.  291. 


.*'rt!S?*l 


-*'«sc 


Lateral  flexion  6t  fetal  body  in  breech  presentation.    (Hodge.) 


the  pelvis,  the  anterior  hip,  as  a  rule,  descending  a  little  lower  than  the 
posterior.  The  breech  being  less  well  fit  to  dilate  the  cervical  canal 
and  the  vagina  than  the  head,  this  descent  is  liable  to  be  slow.  Then 
follows  a  rotation  forward  by  which  the  anterior  hip  is  brought  under 
the  centre  of  the  pubic  arch. 

Simultaneously  with  this  descent  and  rotation  a  strong  lateral /c.r- 
ion  takes  place,  the  body  of  the  foetus  being  bent  with  the  concavity 
towards  the  pubic  arch  (Fig.  291).  The  anterior  hip  is  born  first  and 
soon  followed  by  the  posterior. 

Sometimes  this  rotation  of  the  hips  is  more  or  less  imperfect,  so 


378 


ABNORMAL   LABOR. 


that  the  hips  are  born  in  the  oblique  diameter  or  somewhere  between 
that  and  the  anteroposterior.  Soon  the  lower  extremities  become  free, 
the  feet  coming  out  before  the  legs.  The  arms,  as  a  rule,  remain  pressed 
against  the  thorax.  The  elbows  show  first  in  the  vulva,  and  the 
rest  of  the  arms  and  hands  follow.  When  the  thne  comes  for  the 
shoulders  to  be  delivered,  there  is  again  a  little  rotation  forward  under 
the  pubic  arch,  the  anterior  shoulder  being  born  first,  and  soon  fol- 
lowed by  the  posterior  rolling  over  the  perineum.  By  this  time  the 
longitudinal  diameters  of  the  head  are  in  or  near  the  transverse  diam- 
eter of  the  pelvis,  and  next  the  occiput  is  rotated  forward.  The  nape 
of  the  neck  is  pressed  against  the  pubic  arch,  and  finally  the  chin, 
face,  vertex,  and  occiput  appear  at  the  perineum  (Fig.  292). 

During  this  whole  progression 

through  the  pelvis  the  chin  re- 
,^^  mains  pressed  against  the  chest 

(Fig,  293),  which  favorable  flexion 

Fig.  293. 


Fig.  292. 


Normal  Wrth  of  the  head  In  pelvic-end 
presentations. 


Flexion  of  head  in  pelvic-end  presentation. 
(Zweifel.) 


is  started  by  pressure  being  exercised  through  the  spinal  column  up 
against  the  head,  which  forms  a  two-armed  lever.  The  distance  from 
the  foramen  magnum  to  the  tip  of  the  occiput  being  shorter  than  that 
from  the  foramen  magnum  to  the  chin,  the  occiput  rises  and  the  chin 
descends  until  it  reaches  the  sternum. 

In  exceptional  cases  there  are  deviations  from  this  regular  mechan- 
ism :  the  legs,  instead  of  being  bent  at  the  knees,  may  be  extended  in 


UNFAVORABLE    PRESENTATIOX    OF    F(ETUS. 


379 


front  of  the  anterior  surface  of  the  foetus  (Fig.  294),  or  the  arms  may 
become  extended  on  the  sides  of  the  head,  or  the  occiput  may  remain 
in  the  posterior  part  of  the  pelvis. 

When  the  extremities  are  extended  upward,  artificial  aid  becomes 
necessary  to  accomplish  delivery.  The  extension  upward  of  the  arms 
is  mostly  due  to  attempts  to  pull  out  the  child  by  the  legs. 

When  the  occiput  remains  posteriorly  in  the  pelvis,  the  delivery 
becomes  much  more  difficult  than  when  it  rotates  under  the  pubic  arch. 
In  these  cases,  as  a  rule,  the  face  is  pushed  down  under  the  pubic  arch, 

Fig.  294. 


Legs  extended  in  front  of  the  anterior  surface  of  the  foetus  in  breech  presentation. 


and  at  last  the  occiput  rolls  over  the  perineum.  But  in  a  few  cases 
another  mechanism  has  been  observed.  The  chin  becomes  jammed 
above  the  symphysis,  the  face  turns  upward,  the  occiput  rolls  first  over 
the  perineum,  and  is  followed  by  the  vertex  and  the  face  (Fig.  295). 

The  mechanism  in  foot  and  knee  presentations  is  the  same  as  in 
breech  presentation. 

Prognosis.— Wiih  proper  treatment,  or  rather  if  harmful  interfer- 
ence is  abstained  from,  the  prognosis  of  pelvic  presentations  is,  so  far 
as  the  mother  is  concerned,  as  good  as  that  of  vertex  presentation. 
At  most  the  opening  stage  may  be  somewhat  protracted. 


380 


ABNORMAL   LABOR. 


It  is  very  different  in  regard  to  the  child,  the  infantile  mortality 
being  about  twenty  per  cent.  The  chief  cause  of  this  is  that  the 
umbilical  cord  becomes  compressed  between  the  after-coming  head 
and  the  pelvic  wall,  whereby  the  fetal  respiration  is  arrested.  The 
child  may  endure  a  short  compression  of  the  cord,  but  if  this  con- 
tinues more  than  8  or  9  minutes  the  child  dies,  and  often  it  succumbs 
even  earlier.  Another  cause  of  death  may  be  the  premature  detach- 
ment of  the  placenta,  when  the  larger  part  of  the  body  is  born  and 
the  head  still  is  retained  in  the  uterine  cavity.  It  may  be  also  that  the 
placenta  becomes  compressed  between   the  hard  head  and  the  con- 


FiG.  295. 


Irregular  disengagement  of  head  in  pelvic-end  presentation,  chin  hitched  over  symphysis. 

(Charpentier.) 

tracting  uterine  wall,  and  that  thereby  the  circulation  in  it  is  interfered 
with. 

Footling  presentations  are  worse  than  breech  presentations,  be- 
cause the  legs  are  less  fit  to  expand  the  genital  canal,  while  in  breech 
presentation  the  passage  of  the  after-coming  head  is  much  facilitated. 

Irregularities  in  the  mechanism,  such  as  the  extension  of  the  legs 
in  front  of  the  foetus,  the  extension  of  the  arms  up  by  the  sides  of  the 
head,  and  persistent  occipitoposterior  positions,  make  the  prognosis 
much  less  favorable  than  it  is  in  normal  breech  cases. 

Diagnosis. — By  external  palpation  one  can  in  most  cases  feel  the 
hard  round  fetal  head  at  the  epigastrium  or  the  hypochondrium.  The 
pelvic  end  of  the  foetus  below  is  less  globular,  smaller,  and  softer  than 
the  head.  The  heart  sounds  are,  as  a  rule,  most  distinct  above  the 
level  of  the  umbilicus.     By  vaginal  examination  the  diagnosis  early  in 


UNFAVORABLE    PRESENTATION    OF   FCETUS.  381 

labor  is  quite  difficult  or  impossible.  Maybe  all  we  feel  is  a  bag  of 
water  with  a  movable  small  part,  which  slides  away  and  cannot  be 
recognized  as  a  foot  or  a  hand.  The  mere  fact  that  the  pelvic  cavity 
is  empty  must  awaken  the  suspicion  that  we  have  to  deal  with  a 
pelvic  presentation.  The  bag  of  waters  in  a  footling  presentation  is 
apt  to  be  narrower,  more  fmger-like  than  when  the  broad  head  pre- 
sents. When  the  membranes  rupture,  the  liquor  amnii  is  apt  to  pour 
out  in  a  rush,  since  the  pelvic  end,  and  especially  the  feet,  adapts  itself 
less  well  to  the  os  than  the  globular  head,  which  acts  like  a  ball-and- 
socket  valve. 

When  the  bag  of  waters  is  broken  and  the  presenting  part  within 
reach,  the  diagnosis  becomes  very  easy.  We  then  feel  the  little  hard 
movable  coccyx,  which  is  entirely  characteristic.  So  is  likewise  the 
hard  projecting  ridge  formed  by  the  sacral  crest.  By  either  of  these 
points  we  ascertain  not  only  the  presentation,  but  the  position  as  well. 
We  feel  also  the  tubera  of  the  ischia,  and  midway  between  them  a 
groove.  In  this  we  may,  near  the  tip  of  the  coccyx,  feel  the  anus, 
which,  if  the  child  is  dead,  is  open,  and,  if  it  is  alive,  in  most  cases 
can  be  opened  by  pressing  a  fmger  against  it.  In  withdrawing  the 
finger  we  find  it  soiled  with  meconium.  In  that  groove  we  may 
farther  away  from  the  coccyx  feel  the  large  soft  scrotum  and  the 
cylindrical  movable  penis.  The  female  genitals  are  not  so  easily  rec- 
ognized, and  the  male  ones  may  be  beyond  reach.  Unless  the  male 
organs  are  felt,  it  is,  therefore,  not  safe  to  predict  the  sex  of  the  child. 

The  breech  has  been  taken  for  the  face,  but  the  movable  coccyx, 
the  sharp  crest  of  the  sacrum,  and  the  absence  of  alveolar  ridges 
inside  the  anus  are  more  than  sufficient  to  avoid  such  a  mistake. 

Meconium  may  be  expelled  when  the  child  is  in  head  presenta- 
tion, but  then  it  becomes  mixed  with  and  tinges  the  whole  mass  of 
the  liquor  amnii,  while  in  pelvic  presentation  it  may  be  expelled  and 
found  in  the  vagina  as  the  well-known  black,  thick,  sticky  mass. 

When  a  small  part  is  within  reach,  it  is  of  the  greatest  practical 
importance  to  distinguish  between  a  hand  and  a  foot,  as  the  former 
means  a  shoulder  presentation,  which  demands  a  treatment  entirely 
different  from  that  of  a  pelvic  presentation.  A  foot  is  long  and 
narrow,  has  a  round  projecting  heel,  the  inner  edge  is  much  thicker 
than  the  outer,  and  the  toes  form  a  straight  line  slanting  down  from 
the  big  toe  to  the  little  one.  The  big  toe  cannot  be  opposed  to  the 
others.  The  foot  forms  a  right  angle  with  the  leg,  and  cannot  be 
stretched  out  in  line  with  it.  In  every  one  of  these  respects  it  differs 
from  a  hand,  which  is  shorter  and  broader,  has  edges  of  the  same 
thickness,  has  no  projection  behind,  and  can  easily  be  stretched  in  the 
line  of  the  forearjn.  The  tips  of  the  fingers  form  a  circular  line,  the 
middle  projecting  ahead  of  the  others,  and  the  thumb  is  easily  apposed 


382 


ABNORMAL   LABOR. 


to  every  one  of  the  four  fingers.  The  hand  will  sometimes  grasp  the 
examining  finger,  which  the  foot  cannot  do. 

We  can  not  only  distinguish  a  foot  from  a  hand,  but  we  may  even 
diagnosticate  the  right  from  the  left  foot.  For  this  purpose  we  super- 
pose in  imagination  our  own  foot  over  that  of  the  foetus,  heel  above 
heel,  toes  above  toes,  and  sole  above  instep. 

A  knee  has  so  peculiar  a  shape  that  nothing  is  like  it.  It  forms  a 
large  round  hard  mass  with  a  central  depression  between  two  pro- 
jections. An  elbow  is  smaller,  and  has  a  central  projection,  the 
olecranon,  with  a  depression  on  either  side,  outside  of  which  there 
is  a  smaller  projection — the  condyles  of  the  humerus.  The  heel  is 
also  small,  hard,  round,  with  a  single  tuberosity.  The  shoulder  is 
more  rounded  than  a  knee,  and  has  only  one  prominence,  formed  by 
the  acromion,  from  which  the  clavicle  may  be  felt  starting. 

Fig.  296. 


Liberating  the  posterior  arm  in  breech  presentation. 


Treatment. — It  is  of  the  greatest  importance  not  to  pull  on  the  legs, 
by  which  we  cause  extension  of  the  arms  alongside  the  head  and  re- 
move the  chin  from  the  chest.  The  accoucheur  should  even  carefully 
preserve  the  water-bag,  in  order  to  insure  as  good  a  dilatation  of  the 
genital  canal  as  possible,  and  he  should  leave  the  case  strictly  to 
nature  until  the  child  is  born  as  far  as  the  umbilicus.  Then  he  must 
be  on  the  alert.  He  should,  if  possible,  pull  the  umbilical  cord  down 
in  a  loop,  place  it  in  a  corner  of  the  pelvis  in  front  of  one  of  the 
sacro-iliac  joints,  where  it  is  best  sheltered  against  pressure,  and  con- 
stantly feel  the  pulsation  in  it.  As  long  as  this  is  strong  and  regular, 
there  is  no  danger,  and  no  interference  is  called  for.     If  it  becomes 


UNFAVORABLE    PRESENTATION    OF   FGETUS. 


383 


weak  or  irregular,  the  life  of  the  foetus  is  hi  danger,  and  all  must  he 
done  to  finish  labor  as  rapidly  as  possible.  The  best  thing  to  do  is  to 
seize  the  fundus  uteri  and  exert  pressure  on  the  head  from  above 
during  a  contraction. 

If  the  arms  extend  on  the  sides  of  the  head,  they  must  be  liber- 
ated. For  tliis  purpose  the  thumb  and  first  two  fingers  are  slid  along 
the  arm  from  the  shoulder  to  the  elbow.  Wlien  this  is  reached,  it  is 
easy  to  bend  it  and  get  it  down  in  front  of  the  face  (Fig.  296).  As  a 
rule,  it  is  best  to  liberate  the  posterior  arm  first,  because  here  are 
softer  parts,  and  consecjuently  more  room  can  be  obtained  than  in 
front  at  the  pubic  arch.  In  order  to  get  access  to  the  posterior  arm, 
the  child's  body  should  be  turned  up  over  the  mother's  abdomen, 


Fig.  29/ 


Dorsal  displacement  of  one  arm  across  the  neck  of  the  child. 


and  when  that  arm  is  born  the  body  is  pulled  back  over  the  mother's 
perineum,  which  approaches  the  anterior  arm  to  the  accoucheur's 
fingers. 

If  the  anterior  arm  cannot  be  liberated  in  this  way,  it  is  well  to 
rotate  the  foetus,  so  as  to  move  the  anterior  shoulder  backward.  This 
may  be  done  either  by  seizing  the  fetal  trunk,  pushing  it  upward, 
ancl  rotating  it,  or  by  pulling  the  already  liberated  arm  forward  under 
the  pubic  arcli. 

It  may  happen  that  the  anterior  arm  falls  behind  the  neck  of  the 
child  (Fig.  297),  so  as  to  form  a  cross-bar  above  the  inlet.  By  press- 
ing the  fetal  body  upward  and  rotating  it  in  the  direction  of  the  hand 
the  arm  sometimes  gets  clear  of  the  occiput. 


384 


ABNORMAL   LABOR. 


If  it  does  not,  the  accoucheur  should  try  to  turn  tlie  anterior 
shoulder  back  by  rotating  the  body,  pulling  on  tlie  released  posterior 
arm  or  on  the  elbow  of  the  displaced  arm,  wliile  the  body  is  brought 
"well  back  over  the  perineum  in  order  to  obtain  more  room.  If  the 
arm  cannot  be  dislodged,  and  the  child's  life  is  in  danger,  it  is  proper 
to  pull  down,  even  with  the  risk  of  fracturing  the  humerus.  If  this 
happens,  it  should  be  placed  between  an  anterior  and  a  posterior 
padded  felt  splint  and  fastened  with  bent  elbow  to  the  thorax,  when 
the  fracture  will  heal  in  the  course  of  two  or  three  weeks. 

Whenever  we  try  to  rotate  the  shoulder  by  acting  on  the  body,  we 
must  bear  in  mind  that  the  occipito-atlantic  articulation  admits  only 
a  lateral  rotation  of  a  quarter  of  a  circle.     We  should,  therefore,  by 

Fig.  298. 


Smellie's  method  of  delivering  after-coming  head. 

vaginal  examination  make  sure  that  the  head  follows  the  rotation 
imparted  to  the  shoulders,  as  otherwise  the  cervical  vertebra?  would 
break  and  the  spinal  cord  become  compressed. 

Next,  the  head  must  be  delivered,  and  in  so  doing  we  must 
remember  the  importance  of  having  it  strongly  flexed.  This  may  be 
accomplished  in  different  ways  :  we  may  press  down  on  the  vertex 
through  the  abdominal  wall,  we  may  press  on  the  forehead  from 
the  rectum,  or  we  may  place  two  fingers  on  the  upper  maxilla  in 
the  vagina  and  press  it  down  {Smellie's  method,  Fig.  298). 

A  very  effective  way  is  to  insert  the  right  index-finger  into  the  mouth 
and  draw  the  chin  down  while  the  fingers  of  the  other  hand  pull  on 
the  shoulders  {Levrefs  method). 

If  the  head  is  still  above  the  brim,  it  may  be  delivered  by  pulling 
downward  and  backward  on  the  legs  with   the    right  hand  and  on 


UNFAVORABLE   PRESENTATION    OF   FCETUS. 


385 


the  shoulders  with  the  left  hand  until  the  head  is  in  the  cavity  (Fig. 
299),  when  the  legs  are  suddenly  carried  away  up  over  the  woman's 
abdomen  (Fig.  300).  In  this  way  a  fulcrum  is  obtained  under  the 
pubic  arch,  against  which  presses  the  nape  of  the  neck,  and  the  chin, 
vertex,  and  occiput  are  successively  carried  over  the  perineum.  This 
is  an  old  French  invention,  the  Puzos  method^  much  used  by  modern 
accoucheurs  in  Prague,  and  therefore  known  as  the  Prague  method. 

Very  exceptionally  the  forceps  may  be  applied  to  the  after-coming 
head.  It  takes  more  time,  and,  as  a  rule,  the  manipulations  just  men- 
tioned suffice. 

In  the  delivery  of  the  upper  half  of  the  body  in  pelvic  presenta- 
tions, the  life  of  the  child  is  often  endangered,  and  unless  the  accou- 
cheur succeeds  rapidly  in  delivering  the  arms  and  the  head,  the  child's 
life  is  lost.     He  should  therefore  be  familiar  with  the  different  methods 

Fig.  299. 


Prague  method  of  delivering  after-coming  head,  first  step. 


of  delivery,  so  as  to  be  able  to  pass  promptly  from  one  to  another  if 
the  first  does  not  succeed.  The  personal  experience  of  the  writer 
with  the  after-coming  head  is,  however,  in  favor  of  pressure  on  the 
head  through  the  abdomen  by  an  assistant,  combined  with  the  pull 
on  the  shoulders  and  lower  maxilla. 

The  application  of  the  forceps  to  the  after-coming  head  may  be 
difficult,  especially  if  there  is  a  spastic  contraction  of  the  lower  uterine 
segment  or  when  the  face  is  turned  laterally  in  the  pelvis.  The 
instrument  may  hitch  against  the  chin  or  the  nose,  which  should  be 
protected  by  inserting  the  guiding  hand  deeply.  The  forceps  should 
be  applied  below  the  body  of  the  child,  so  as  to  have  room  to  bring 
the  handles  down.  The  trunk  and  extremities  of  the  child,  wrapped 
up  in  warm  flannel,  should  be  held  by  an  assistant.  Special  attention 
should  be  paid  to  the  navel-cord,  so  as  to  avoid  compressing  it  with 
the  forceps. 

25 


386 


ABXORAIAL    LABOR. 


In  sacroposterior  positions  of  tlie  breech  we  may  favor  rotation  by 
hooking  the  index-finger  in  tlie  anterior  or  botli  groins. 

If  the  head  remains  in  the  occipitoposterior  position,  we  may 
facilitate  rotation  by  pressing  the  anterior  temple  backward.  If  the 
head  does  not  yield,  we  must  try  to  imitate  the  natural  meclianism 
by  pushing  the  occiput  up  and  pulling  the  body  well  back  in  order 
to  draw  the  face  down  under  the  pubic  arch.  If  that  too  fails  and 
the  chin  is  hitched   oatp   the  symphysis    pubis,   an    attempt    should 

JFiG.  300. 


Prague  method  of  delivering  after-coming  head,  second  step. 


be  made,  by  pulling  well  forward,   to   deliver  the  occiput   over  the 
perineum,  when  the  remainder  of  the  head  will  follow. 

If  the  breech  becomes  impacted  in  the  pelvic  cavity,  three  methods 
of  overcoming  the  difficulty  are  at  our  command :  to  bring  down  one 
or  both  legs,  to  pull  on  the  groin,  or  to  apply  the  forceps.  If  the  breech 
can  be  raised  sufficiently  to  make  room  for  the  hand  or  arm,  the 
first  method  is  the  best.  If  the  feet,  as  usual,  are  found  near  the 
breech,  this  is  even  not  difficult :  but  if  the  legs  are  extended  in 
front  of  the  foetus,  it  is  necessary  to  go  all  the  Avay  up  to  the  fundus 
in  order  to  get  hold  of  the  feet  and  break  up  the  wedge  formed  by 


UNFAVORABLE    PRESENTATION   OF   FCETUS. 


387 


the  foelus  ;  or  we  must  at  least  reach  beyond  the  knees,  when  perhaps 
we  may  be  able  to  bend  them  and  thus  bring  the  foot  nearer. 

If  the  accoucheur  wants  to  bring  down  a  foot  he  seizes  it  between 
the  index  and  middle  finger  above  the  ankles  and  the  thumb  on  the 
sole.  (See  Version,  Fig.  455.)  As  it  is  quite  slippery,  he  may  have 
some  difficulty  in  holding  it.  Then  a  good  grip  may  be  obtained  by 
carrying  a  fillet  around  the  foot  above  the  ankles.  I  use  tape  a  quar- 
ter of  an  inch  wide.  First  a  slip-knot  is  made,  which,  with  a  little 
practice,  can  be  done  with  one  hand.  The  loop  is  carried  on  the 
thumb  and  first  two  fingers  (Figs.  458,  459,  460),  and  pushed  over  the 

Fig.  301. 


mP- 


Mode  of  passing  fillet  over  foot. 

foot  with  the  fingers  of  the  other  hand  (Fig.  301),  which  thereafter 
pulls  the  slip-knot  tight. 

If  the  breech  is  so  low  down  as  to  fill  the  pelvic  cavity  and  pre- 
vent us  from  passing  the  hand  and  arm,  we  should  try  to  hook  the 
index-finger  into  the  groins  of  the  foetus,  or  at  least  into  the  anterior 
groin,  until  we  can  get  hold  of  both  and  pull  the  breech  down.  But 
if  the  breech  sticks  high  up  we  have  a  rather  weak  grip  on  it  in  this 
way,  and  our  power  is  very  much  increased  if  we  can  pass  a  fillet 
over  the  anterior  groin.  In  our  aseptic  times  the  accoucheur  can, 
however,  no  longer  pull  off  his  silk  necktie  and  draw  it  over  the 
groins  with  a  copper  wire,  even  if  he  can  secure  one,  as  we  formerly 
did.  A  disinfected  linen  tape  is  good,  and  may  be  hauled  into  position 
by  means  of  Olivier's  fillet-carrier  (Fig.  302). 


388 


ABNORMAL   LABOR. 


The  hard  Hnen  tape  may,  however,  cut  into  the  soft  tissue  at  the 
groin.  A  better  contrivance  is  to  take  lacing  covered  by  rubber 
tubing,  which  is  stitched  to  it. 

Olivier's  fillet-carrier  consists  of  a  metal  tube  bent  into  a  hook 
and  provided  with  a  handle.     Through  the  tube  runs  a  whalebone 

Fig.  302. 


G:x\tWM\u&to. 


^S 


Olivier's  fillet-carrier. 

with  a  metal  end  perforated  so  as  to  form  an  eye.  The  hook  is 
carried  over  the  outer  side  of  the  anterior  hip,  and  when  its  end  lies 
between  the  thighs,  the  Avhalebone  is  pushed  forward  till  it  appears 
outside  the  vulva.  Then  the  fillet  is  attached  to  the  eye,  and  the 
whalebone  withdrawn,  and  finally  the  hook  is  disengaged  and  with- 
drawn, carrying  the  fillet  along  (Fig.  303). 


Fig 


Fillet  in  groin  in  sacro-anterior  position.     (Olivier.) 


If  the  foetus  is  in  sacroposterior  position,  there  is  danger  of  the 
fillet  slipping  forward  on  the  thigh  (Fig.  304).  When  traction  is  then 
made,  we  might  fracture  the  femur.     Care  must  therefore  be  taken 


UNFAVORABLE   PRESENTATION    OF   FCETUS. 


389 


to  push  the  fillet  well  down  to  the  groin,  which  may  be  facilitated 
by  introducing  a  finger  into  the  anus  and  pulling  forward. 

If  no  special  instrument  is  at  hand  to  carry  the  fillet  around  the 
groin  Avith,  it  may  be  done  with  a  flexible  catheter.     It  is  first  intro- 

FiG.  304. 


ri]let  on  thigh  in  sacroposterior  position.     (Olivier.) 

duced  curved  with  the  stylet  all  the  way  through.  Next  the  stylet  is 
partly  withdrawn,  which  makes  the  tip  dip  down.  When  it  has  been 
pulled  outside  the  vulva  with  the  fingers  or  a  pair  of  artery-forceps, 
the  stylet  is  again  pushed  through  as  far  as  the  eye.  A  silk  thread 
attached  to  the  fillet  is  passed  around  the  stylet  and  tied,  and  then 
the  stylet  is  pushed  through  to  the  end.  If  we  now  pull  the  catheter 
back,  the  string  and  the  fillet  must  follow. 

Fig.  305. 


Blunt  hook. 


Instead  of  the  soft  fillet  some  pass  a  hUnt  hook  over  the  groin 
(Fig.  305).  It  is  passed  like  Ollivier's  fillet-carrier,  but  is  more  apt 
to  cause  fracture  of  the  thigh  bone. 


390 


ABNORMAL   LABOR. 


After  the  leg  or  legs  have  come  out,  they  should  be  surrounded 
by  a  piece  of  gauze  or  muslin,  which  takes  away  the  slipperiness, 
and  in  extracting  the  accoucheur  should  always  take  hold  as  near  as 
possible  to  the  genitals,  first  working  on  the  feet,  then  on  the  knees, 
then  on  the  hips,  and  finally  on  the  thorax. 

Although  the  forceps  originally  were  designed  only  for  application 
to  the  head,  it  may  be  used  with  advantage  also  on  the  breech.  One 
blade  should  be  applied  over  the  sacrum  and  the  other  over  the  pos- 
terior surface  of  the  thighs.  If  the  breech,  however,  is  in  the  trans- 
verse diameter,  the  blades  should  be  applied  to  the  outer  surface  of 
the  thighs  (Fig,  306).      It  is  not  advisable  to  apply  them  over  the 

Fig.  306. 


Tarnier  forceps  applied  to  breech  in  transverse  diameter.     (Olivier.) 


trochanters  and  the  crests  of  the  ilium,  as  in  this  position  the  for- 
ceps is  apt  to  slip. 

If  dehvery  is  impossible,  the  fetal  pelvis  may  be  crushed  and  ex- 
tracted with  the  cephalotribe,  or,  if  that  instrument  is  not  available, 
the  pelvis  may  be  diminished  with  perforator  and  extracted  with  for- 
ceps. If  the  head  is  arrested  and  the  child  is  dead,  embryotomy  may 
be  performed  through  the  spinal  canal  and  the  foramen  magnum. 
When  the  brain  matter  is  pressed  out,  the  head  becomes  so  much 
smaller  that  it  can  easily  be  extracted. 

In  breech  deliveries  the  serosanguineous  swelling  is  formed  on  the 
presenting  part,  ordinarily  the  anterior  nates,  and  extends  over  the 
genitals,  which  may  become  much  swollen. 


UNFAVORABLE    PRESENTATION    OF    F(ETUS. 


391 


Fig.  307 


The  skull  is  compressed  in  the  occipitofrontal  diameter  and  bulges 
out  at  the  top,  so  as  to  become  brachycephalic  and  globular  (Fig.  307). 

§  7.  Transverse  Presentations. — A  transverse  presentation,  or 
cross  birth,  is  the  condition  in  which  the  long  axis  of  the  foetus  does 
not  correspond  to  the  long  axis  of  the  uterus,  but  is  placed  more  or 
less  transversely  in  the  same.  It  is  rarely  found  just  at  right  angles 
to  the  long  axis  of  the  uterus,  but  slants  more  or 
less  to  one  side,  the  head,  as  a  rule,  being  on  a 
lower  level  than  the  breech.  Generally,  nature 
does  not  suffice  to  accomplish  delivery  in  these 
presentations.  If  no  help  can  be  obtained,  out- 
side of  very  exceptional  cases,  which  will  be  con- 
sidered presently,  the  woman  dies  undelivered. 

We  distinguish  two  positions  in  cross  presen- 
tation :  in  the  first,  or  dorso-anterior,  the  back  of 
the  child  is  turned  forward  against  the  abdomi- 
nal wall  (Fig.  112,  p.  82).  In  the  second,  or 
dorsoposterior  position,  the  back  is  turned  back- 
ward against  the  vertebral  column  of  the  mother 
(Fig.  Ill,  p.  81).  Any  part  of  the  body,  or  a 
hand,  elbow,  or  arm  may  present ;  but  in  the 
course  of  time  the  shoulder  almost  invariably 
becomes  the  lowest  point,  and  therefore  these 
presentations  are  also  known  as  shoulder  p)resen- 
tations.  The  head  may  be  either  in  the  left  or 
the  right  iliac  fossa,  more  frequently  in  the  left, 
and  the  dorso-anterior  position  is  about  twice  as 
common  as  the  dorsoposterior.  But  all  trans- 
verse positions  are  rare,  occurring  only  in  little  more  than  one-half 
of  one  per  cent,  of  labor  cases. 

The  transverse  presentation  may  be  primary  or  secondary.  During 
pregnancy  it  is  not  very  rare,  but  as  a  rule  the  presentation  in  multi- 
parse  is  corrected  to  a  vertex  presentation  by  the  contractions  of  the 
uterus.  In  other  cases  the  primary  transverse  position  continues, 
and  in  others  again  the  presentation  may  at  first  be  normal,  and  it 
is  only  during  labor  that  the  secondary  transverse  presentation  is 
produced. 

Etiology. — Transverse  presentations  are  found  much  more  fre- 
quently in  multiparse  than  in  primiparae,  in  whom  both  the  uterine 
wall  and  the  abdominal  wall  are  much  more  resistant,  and  the  uterine 
cavity  has  a  more  perfect  form.  In  a  primipara  the  transverse  pre- 
sentation is  hardly  found,  unless  she  has  a  narrow  pelvis.  But  some 
women  doubtless  have  an  abnormally  shaped  uterus,  the  ovoid  lying 
transversely  instead   of  perpendicularly.      This  is  not  anatomically 


The  shape  of  the  skull 
of  the  after-eomiug  head. 
(Charpentier.) 


392  ABNORMAL   LABOR. 

proved,  but  we  are  driven  to  this  conclusion  by  the  fact  that  some 
vi^omen  in  every  or  nearly  every  labor  have  a  transverse  presentation. 
Great  obliquity  of  the  uterus  may  cause  the  presenting  part  to  slide 
away,  which  may  result  in  a  transverse  presentation.  The  most  com- 
mon cause  is  a  narrow,  especially  a  flat,  pelvis,  which  prevents  the 
head  from  being  engaged.  Tumors,  uterine  or  others,  may  have  a 
similar  effect.  Also  a  low  attachment  of  the  placenta,  especially  pla- 
centa praevia.  The  second  twin  is  comparatively  often  found  placed 
transversely.  Hydramnion  and  a  sudden  escape  of  the  liquor  amnii 
or  a  fall  may  cause  the  displacement.  It  occurs  particularly  with 
small,  dead,  especially  macerated,  foetuses. 

Diagnosis. — The  diagnosis  is  as  a  rule  easy.  By  mere  inspection 
we  notice  that  the  abdomen  is  unusually  broad.  By  abdominal  pal- 
pation we  find  that  the  transverse  diameter  of  the  uterus  is  longer 
than  the  longitudinal.  As  a  rule,  the  hard,  globular  head  is  felt  in  one 
iliac  fossa  and  the  smaller  and  softer  breech  in  the  other  side.  Often 
we  can  also  feel  the  cylindrical  resistant  back  or  the  feet  turned  for- 
ward. 

The  heart-sounds  are  heard  in  the  lower  part  of  the  abdomen, 
and  are  propagated  most  distinctly  through  the  back  of  the  foetus. 

By  vaginal  exploration  executed  early  in  labor  we  find  the  pelvis 
empty,  and  in  the  bag  of  waters  we  may  feel  a  small,  movable  part, 
the  nature  of  which  cannot  be  recognized,  or  the  back.  Later,  when 
the  membranes  rupture  and  the  foetus  is  pressed  down,  the  diagnosis 
becomes  easy.  As  a  rule,  we  feel  the  shoulder,  perhaps  also  the 
spine  of  the  scapula  or  the  collar-bone.  The  shoulder  is  a  soft  con- 
vex mass  running  out  into  a  bony  ridge,  the  acromion.  It  has  been 
mistaken  for  the  breech,  but  in  breech  presentations  we  have  the 
second  buttock,  the  groove  with  the  anus  and  genitals,  the  movable 
coccyx,  and  the  crest  of  the  sacrum. 

Sometimes  we  may  feel  the  axilla  and  the  ribs  with  intercostal 
spaces,  which  are  not  like  anything  else.  The  elbow  is  recognized  by 
the  large  central  projection  formed  by  the  olecranon  and  two  smaller 
projections,  one  on  either  side — the  condyles  of  the  humerus. 

By  vaginal  examination  we  can  in  this  way  make  the  diagnosis, 
not  only  of  a  transverse  presentation ;  but,  what  is  of  great  practical 
importance  for  the  treatment,  we  can  also  decide  in  what  position  the 
fcetus  lies.  The  shoulder-blade  marks  the  back  and  the  collar-bone 
the  front.  The  lower  angle  of  the  scapula  points  in  the  direction  of 
the  feet.  The  axilla  opens  likewise  in  the  direction  of  the  feet.  If  an 
arm  is  prolapsed  and  we  bring  it  into  easy  relation  to  the  trunk,  the 
back  of  the  foetus  is  on  the  same  side  as  the  back  of  the  hand,  the 
palm  corresponds  to  the  abdomen,  the  thumb  points  to  the  head,  and 
the  little  finger  to  the  feet.     It  is  easy  to  make  out  whether  we  have 


UNFAVORABLE    PRESENTATION    OF    FCETUS.  393 

to  deal  with  the  right  or  the  left  hand.  For  this  purpose  we  need  only 
to  grasp  the  hand  as  in  hand-shaking,  the  two  thumbs  being  in  contact. 
The  fetal  hand  is  then  homonymous  with  that  of  the  accoucheur. 
In  studying  obstetrics  it  is  a  great  help  to  have  a  female  pelvis,  a  fetal 
head,  and  a  doll  with  movable  joints.  In  this  way  all  these  descrip- 
tions of  presentations  and  positions  become  quite  plain. 

If  the  hip  presents,  we  may  feel  the  groin,  the  anterior  superior 
spine  and  the  crest  of  the  ilium.  Rarely  the  back  or  the  abdomen 
presents.  The  former  is  recognized  by  the  spinous  processes,  the 
latter  by  the  cord. 

If  the  diagnosis  cannot  be  made  otherwise,  it  has  been  recom- 
mended to  bring  down  the  arm.  This  would  hardly  interfere  with 
the  measures  to  be  taken  subsequently,  but  it  is  better  to  avoid  it. 

Prognosis. — The  prognosis  as  a  whole  is  pretty  bad. 

The  maternal  mortality  is  about  11  per  cent.,  and  that  among  the 
children  about  50  per  cent.,  but  it  makes  the  greatest  difference 
whether  the  case  comes  under  treatment  early  or  late,  and  whether 
the  accoucheur  acts  intelligently  or  not.  While  a  case  seen  before  the 
membranes  rupture,  in  all  probability  will  end  safely  for  mother  and 
child,  a  neglected  one  may  end  in  the  loss  of  both. 

Course. — In  transverse  presentation  the  opening  of  the  cervix  and 
OS  is  slow,  there  being  no  wedge  to  press  on  them  as  in  longitudinal 
presentations.  The  bag  during  the  interval  between  contraction  hangs 
down  as  a  narrower  pouch  than  in  head  presentations.  When  the 
membranes  rupture,  the  liquor  amnii  is  apt  to  pour  out  in  a  gush, 
there  being  no  part  that  adapts  itself  well  enough  to  the  cervix  to 
retain  the  fluid.  This  gush  of  fluid  may  cause  the  prolapse  of  the 
umbilical  cord  or  of  an  arm  (Fig.  308).  The  upper  part  of  the  uterus 
may  contract  and  press  the  presenting  part  with  such  force  against  the 
lower  uterine  segment  that  this  may  give  way  and  the  woman  die 
from  hemorrhage  or  peritonitis.  Later  the  shoulder  becomes  jammed 
in  the  pelvis.  The  fetal  body  is  flexed  laterally,  so  that  head  and 
breech  approach  each  other.  The  uterine  contractions  assume  a  tetanic 
character  or  die  out.  Microbes  may  enter  the  uterus  and  make  it 
swell  with  gas — tympania  uteri,  or  physometra.  The  woman  may  die 
from  exhaustion  or  from  sepsis. 

There  are  two  ways  in  which  nature  can  accomplish  delivery, 
spontaneous  version  or  spontaneous  evolution,  but  both  are  so  danger- 
ous that  the  accoucheur  should  never  wait  for  them. 

Spontaneous  version  consists  in  the  substitution  of  one  presenting 
part  for  another,  and  may  end  as  a  breech  or  head  presentation.  It 
can,  as  a  rule,  take  place  only  before  the  rupture  of  the  membranes  or 
shortly  after,  but  it  has  been  observed  even  after  the  shoulder  was  in 
the  pelvis  or  an  arm  had  prolapsed.    In  Genesis,  chap,  xxxviii.  28-29, 


394 


ABNORMAL   LABOR. 


a  case  of  twins  is  reported  in  which  the  midwife  marked  the  prolapsed 
arm  with  a  thread.  The  foetus  next  withdrew  this  arm,  and  the  other 
twin  was  born  first. 

Spontaneous  evolution  comes  late  in  labor.  In  this  mode  of  delivery 
the  prolapsed  arm  remains  outside,  and  the  doubled-up  body  of  the 
foetus  is  pressed  through  the  pelvis  (Figs.  309-312).  This  is  only  pos- 
sible* if  the  pelvis  is  unusually  large  or  the  foetus  exceptionally  small. 
Most  of  the  children  have  been  twins,  immature  or  dead,  but  in  a  few 
cases  living  children  have  been  born.  The  mechanism  is  twofold.  In 
most  cases  the  head  remains  in  the  large  pelvis  over  the  iliopectineal 

Fig.  308. 


Prolapse  of  arm  in  transverse  presentation.     (Tarnier  and  Chantreuil,  1.  c.) 


line.  The  shoulder  turns  forward  and  is  pressed  out  under  the  pubic 
arch,  and  stays  there  till  the  child  is  born.  The  thorax  is  strongly 
curved  and  gradually  pushed  out.  Next  the  hip  rotates  under  the 
pubic  arch  and  the  legs  are  extended  in  front  of  the  foetus.  When  they 
have  been  expelled,  the  head  is  born  together  with  the  second  arm, 
which  is  extended  alongside  of  it. 

In  the  other  mechanism  the  head  passes  through  the  pelvis  together 
A\dth  the  thorax.  First  the  shoulder  is  born,  then  the  thorax  and 
head  together,  and  last  the  breech  and  lower  extremities. 

Treatment. — If  the  patient  is  seen  during  pregnancy,  the  head 
should  be  brought  down  over  the  brim  of  the  pelvis  by  external  ma- 


Fig.  309.— Spontaneous  evolution,  first  stage. 


Fig.  310.— Spontaneous  evolution,  second  stage.  Fig.  311.— Spontaneous  evolution,  third  stage. 


Fig.  312. — Spontaneous  evolution,  fo\irth  stage. 


UNFAVORABLE   PRESENTATION    OF   FCETUS.  395 

nipulations  and,  if  possible,  kept  there  by  the  apphcation  of  a  tightly- 
fitting  abdominal  supporter.  Where  economy  is  an  object,  a  flannel 
binder  surromiding  the  whole  abdomen  and  tightly  pinned  may  be 
substituted  for  the  work  of  the  bandagist. 

If  the  woman  is  taken  in  labor  prematurely  before  the  end  of  the 
sixth  month  of  pregnancy,  the  case  may  be  left  to  nature.  Until  that 
time  the  foetus  is  so  small  and  soft  that  it  may  be  expelled  by  sponta- 
neous evolution  without  harm  to  the  mother,  and  it  is  not  viable.  After 
that  period  version  is  indicated. 

In  the  beginning  of  labor  external  version  bringing  down  the  head 
over  the  brim  of  the  pelvis  is  also  indicated,  and  then  the  patient 
should  lie  on  the  side  where  the  head  was,  for  by  so  doing  the  fundus 
uteri  is  tilted  over  to  this  side  and  the  head  pushed  in  the  opposite 
direction.  The  effect  of  this  lateral  posture  may  still  be  heightened 
by  placing  under  the  flank  upon  which  the  woman  rests  a  bolster  or  a 
pillow  rolled  up  so  as  to  form  a  cylinder,  and  tied  at  both  ends  and  in 
the  middle.  The  writer  has  also  succeeded  in  retaining  the  head 
below  by  keeping  the  patient  on  the  back,  and  rolling  two  towels  so 
as  to  form  hard,  sausage-shaped  masses,  one  of  which  is  placed  on 
either  side  of  the  abdomen  and  held  in  place  by  a  tight-fitting  binder. 
The  patient  should  under  no  circumstance  lie  on  the  side  where  the 
breech  is,  as  this  would  favor  deviation. 

The  membranes  should  be  preserved  as  long  as  possible  in  order 
to  obtain  a  good  dilatation  of  the  cervix  and  os  which  will  facilitate 
further  manipulations  and  the  birth  of  the  child.  No  examination 
should  be  made  during  uterine  contraction,  as  then  the  membranes 
are  more  endangered.  The  membranes  may  be  supported  and  dila- 
tation furthered  by  placing  a  colpeurynter  in  the  vagina. 

If  the  membranes  rupture  before  the  os  is  fully  dilated,  it  is 
advisable  to  try  to  perform  version  according  to  Braxton  Hicks's 
method  and  bring  down  a  leg.  But  perhaps  the  cervix  can  be  arti- 
ficially dilated,  and  then  it  is  more  expeditious,  and  therefore  better, 
to  insert  the  whole  hand  into  the  uterus,  perform  podalic  version,  and 
extract  at  once,  and  the  same  is  to  be  done  without  awaiting  full  dila- 
tation at  any  time  when  the  mother's  or  the  foetus's  life  is  in  danger. 

In  cases  that  have  been  so  neglected  that  all  water  has  drained  off, 
that  the  uterus  is  tetanically  contracted  around  the  foetus,  and  that  it 
is  impossible  to  dislodge  the  shoulder,  an  attempt  should  be  made  to 
further  spontaneous  evolution  by  pulling  on  the  presenting  part. 

If  that,  too,  fails  nothing  is  left  but  embryulcia  or  decapitation. 
(See  Operations.) 

§  8.  Compound  Presentation.' — When  an  upper  or  a  lower  ex- 

^  Garrigues,  "A  Case  of  Presentation  of  the  Head,  Hand,  Foot,  and  Cord," 
New  York  Med.  Jour.,  June  16,  1883,  vol.  xxxviii.,  No.  24,  p.  650. 


396  ABNORMAL   LABOR. 

tremity  presents  beside  the  head,  it  is  called  a  compound  or  complex 
presentation. 

A.  Upper  Extremity. — It  is  by  no  means  rare  that  a  hand  is  felt 
behind  the  presenting  head,  but  generally  it  is  withdrawn,  or,  if  it 
stays,  it  is  without  importance,  since  the  hand  allows  the  head  to  pass. 
No  interference  is  called  for. 

The  presence  of  an  arm  is  much  more  serious,  since  there  may 
not  be  room  enough  for  both  head  and  arm  to  pass  together  through 
the  pelvis.  If  it  is  the  posterior  arm  that  accompanies  the  head,  the 
chances  are  better,  for  there  is  more  room  behind ;  but  the  anterior 
arm  may  prevent  the  internal  rotation  of  the  head  and  make  the  head 
remain  in  the  transverse  diameter  of  the  pelvis  or  drive  the  occiput 
back  into  the  hollow  of  the  sacrum. 

Sometimes  a  rotation  takes  place  by  which  the  anterior  arm 
becomes  the  posterior. 

If  the  case  is  seen  before  the  membranes  rupture,  the  accoucheur 
should  try  to  push  the  arm  up  cautiously  without  rupturing  the  mem- 
branes, and  then  press  on  the  head  from  above,  in  order  to  make  it 
engage.  The  patient  ought  to  be  placed  on  the  side  opposite  to  that 
where  the  arm  is.  If  the  membranes  are  ruptured,  he  should  still 
try  to  move  the  prolapsed  arm  upward  in  front  of  the  face,  which  he 
often  can  do  with  the  thumb  and  two  fingers,  and  when  there  is  no 
longer  room  for  the  thumb,  he  uses  the  two  fingers  alone.  In  face 
presentations  the  arm  is  pushed  over  the  chin  and  chest. 

If  the  arm  cannot  be  replaced,  and  the  uterine  contractions  are 
not  strong  enough  to  bring  the  head  down  beside  the  arm,  traction 
should  be  made  on  the  head  with  the  forceps,  or  if  the  child  is  dead 
craniotomy  should  be  performed. 

In  rare  cases  the  arm  lies  across  and  behind  the  neck  (Fig.  313)^ 
forming  a  bar  which  hitches  on  the  brim  of  the  pelvis  and  prevents 
the  head  from  advancing.  This  condition  may  be  surmised  if  progress 
of  labor  stops,  although  there  is  no  visible  obstruction.  The  diagnosis 
can  only  be  made  by  ansesthetizing  the  patient  and  pushing  the  hand 
sufficiently  deep  in  to  feel  the  obstacle.  As  soon  as  the  nature  of  the 
case  is  ascertained,  the  accoucheur  should  seize  the  forearm  and  try 
to  bring  it  down,  changing  the  condition  into  an  ordinary  head-and- 
arm  case,  and  if  he  does  not  succeed  in  this  attempt,  he  should  per- 
form podalic  version  and  extract. 

B.  Lov)er  Extremity. — One  or  both  feet  may  present  with  the 
head  and  descend  with  it,  but  this  is  a  rare  occurrence,  which  happens 
mostly  when  the  foetus  is  immature  or  dead.  First  we  try  to  replace 
the  extremity,  and,  if  that  is  not  feasible,  podahc  version  should  be 
performed.  But  to  pull  on  the  prolapsed  leg  only  increases  the  diffi- 
culties.    As  the  leg  is  drawn  down,  the  foetus  becomes  more  and  more 


EXCESSIVE   SIZE    OF   FOETUS. 


397 


bent  to  one  side  and  the  head  does  not  move.  But  by  bringmg  down 
the  other  leg  and  pullmg  on  that  we  make  the  foetus  rotate  on  its  long 
axis,  the  extremities  which  are  jammed  together  with  the  head  in  the 


Fig.  313. 


Dorsal  displacement  of  arm  in  vertex  presentation. 

pelvis  are  raised,  the  bent  side  becomes  straightened  out,  and,  finally, 
the  head  recedes  from  the  pelvis,  and  is  delivered  as  described  in 
treating  of  pelvic  presentations. 

If  the  foetus  is  dead  and  impacted,  the  head  should  be  perforated 
and  extracted  with  forceps.  If  the  foetus  is  small  and  freely  movable, 
it  may  be  turned  and  extracted. 


CHAPTER    IV. 

EXCESSIVE   SIZE    OF    FCETUS. 

The  foetus  may  be  of  unusual  size,  either  in  general  or  in  particu- 
lar parts  of  the  body. 

§  1.  Giant  Children. — Some  children  are  of  enormous  propor- 
tions. The  greatest  weight  observed  was  nearly  twenty-five  pounds 
and  the  greatest  length  thirty  inches. 

But  apart  from  these  very  exceptional  cases,  some  children  are 
so  large  that  they  constitute  an  impediment  to  childbirth  through  a 
normal  pelvis. 


398  ABNORMAL   LABOR. 

Large  Head. — It  is  particularly  the  head  that  gives  trouble,  not 
only  by  its  size,  but  also  by  its  lack  of  compressibility.  As  a  rule, 
the  two  go  together,  the  large  head  being  harder  than  the  small.  In 
some  heads  ossification  is  too  advanced.  The  sutures  are  too  narrow, 
the  fontanelles  too  small,  and  the  head  so  hard  that  normal  mould- 
ing is  rendered  difficult  or  impossible.  Other  heads  are  simply  too 
large,  which  is  apt  to  lead  to  pelvic  presentation  or  rarely  to  cross 
presentation. 

Male  children  have  on  an  average  larger  heads  than  female  chil- 
dren. The  older  the  mother  is  the  larger  the  head  of  the  child 
becomes.  The  size  of  the  head,  especially  the  length  of  the  biparietal 
diameter,  increases  with  the  number  of  pregnancies  up  to  the  seventh. 
Large  women  are  apt  to  have  large  and  heavy  children.  The  size  of 
the  father  also  influences  the  size  and  weight  of  the  child.  A  large 
man  is  likely  to  engender  large  children. 

Diagnosis. — The  diagnosis  of  a  large  head  may  be  difficult  during 
pregnancy  or  in  the  beginning  of  labor,  especially  in  stout  women. 
But  in  most  cases  we  can  form  a  pretty  accurate  idea  of  its  propor- 
tions by  seizing  it  above  the  brim  with  thumb  and  index-fmger  and 
placing  the  other  index-fmger  on  it  from  the  vagina. 

Sometimes  the  small  size  of  the  large  fontanelle  or  the  unusual 
length  of  the  sagittal  suture  may  be  felt  by  vaginal  examination.  If 
the  head  does  not  engage  or  if  labor  does  not  progress,  although  the 
pelvis  is  normal,  it  may  be  surmised  that  the  head  is  large.  A  posi- 
tive diagnosis  can  only  be  made  by  introducing  the  whole  hand  into 
the  uterine  cavity  and  palpating  the  head. 

Prognosis. — As  a  rule,  the  case  may  be  brought  to  a  successful 
end  for  both  mother  and  child,  but  some  children  die. 

Treatment. — If  nature's  sole  efforts  are  insufficient  to  terminate 
labor,  the  child  should  be  extracted  with  forceps.  The  writer  has 
delivered  a  child  weighing  nearly  eleven  pounds  successfully  for 
mother  and  child  by  means  of  symphyseotomy.  Csesarean  section 
has  been  performed  in  order  to  deliver  a  giant  child.  This  is  an 
operation  by  which  the  abdominal  wall  and  the  uterus  are  incised 
and  the  child  is  extracted  through  the  incision.  (See  Operations.)  If 
the  child  is  dead,  the  head  should  be  perforated  and  extracted  with 
forceps,  the  cranioclast,  or  the  cephalotribe'.     (See  Operations.) 

Large  Body. — It  is  much  more  rarely  the  size  of  the  body  that 
prevents  progress  of  labor.  The  body  being  so  much  more  com- 
pressible than  the  head,  where  the  latter  has  passed,  generally  the 
former  can  follow.  If  it  does  not  do  so,  we  may  help  deliver  it  by 
rotating  the  shoulder  forward  or  by  pulling  the  arms  down,  always 
taking  the  posterior  first,  because  there  is  more  room  behind  in  the 
pelvis,  and  when  the  posterior  is  out,  the  liberation  of  the  anterior 


EXCESSIVE    SIZE    OF    FOETUS. 


399 


becomes  easier.  The  hips  may  also  need  help  to  rotate  and  to  come 
down. 

Very  rarely  evisceration  (see  Operations)  may  become  necessary. 

§  2.  Hydrocephalus. — Hydrocephalus  is  a  collection  of  serum  in 
the  ventricles  of  the  brain,  by  w^hich  the  head  of  the  foetus  becomes 
enlarged  (Figs.  314,  315).  The  bones  of  the  skull  are  thin,  sutures 
and  fontanelles  very  large.  The  face  remains  small,  and  the  body  is 
often  wasted  and  shrivelled.  In  most  cases  the  vertex  presents,  but 
pelvic  presentation  is  unusually  common  with  hydrocephalus.  On 
account  of  the  great  compressibility  of  the  head,  it  may,  in  spite  of 
its  size,  become  engaged  and  pass  through  the  pelvis  as  a  sausage- 

FiG.  314. 


Hydrocephalus. 

shaped  mass.  Or  the  head  may  rupture,  giving  outlet  to  the  fluid, 
when  the  child  may  be  born.  Hydrocephalus  is,  fortunately,  a  rather 
rare  disease. 

Diagnosis. — The  diagnosis  is  often  difficult,  especially  in  breech 
presentation.  By  abdominal  palpation  we  may  be  able  to  feel  the 
large  head  above  the  brim  or  at  the  fundus.  If  the  head  presents, 
we  may  feel  the  large  sutures  and  fontanelles  and  notice  the  thinness 
of  the  bones  of  the  skull.  Sometimes  Wormian  bones  are  felt  in  the 
sutures.  If  we  cannot  account  for  the  non-engagement  of  the  head, 
the  whole  hand  may  be  passed  into  the  uterus,  when  we  will  be  able 
to  feel  the  size  of  the  skull,  the  large  sutures  and  fontanelles,  the 
thin  bones,  and  the  abnormal  compressibility  of  the  head.  But  if  the 
lower  uterine  segment  is  much  distended,  we  might  rupture  it,  and  it 
then  is  safer  to  abstain  from  this  procedure.  In  breech  presentations 
we  may  surmise  the  condition  from  the  poor  development  of  the  body. 


400 


ABNORMAL   LABOR. 


Prognosis. — The  prognosis,  so  far  as  the  child   is  concerned,  is 
decidedly  bad.     Most  of  the  children  die  during  labor  or  shortly  after 
their  birth.     For  the  mother  the  prognosis  is  not  so  bad,  but  still 
serious.     Frequently  the  lower  uterine  segment  ruptures,  and  pro- 
longed pressure  on  the  cer- 
FiG.  315.  vix  and  pelvic  tissues  leads 

often  to  infection,  which 
may  end  fatally.  The  oper- 
ative treatment,  if  properly 
performed,  ought  not  now- 
adays to  endanger  her  life 
or  health.  The  frequency 
of  the  pelvic  presentation  is 
in  her  favor,  since  the  small 
body  is  easily  borne  and 
the  head  can  be  diminished 
before  it  commences  to 
press  on  the  maternal  tis- 
sues. 

Treatment. — If  the  vertex 
presents,  the  fluid  may  be 
aspirated  and  thus  the  head 
diminished  without  neces- 
sarily killing  the  child.  It 
is  true  these  children  are  of 
little  value,  and  we  should 
certainly  let  their  life  weigh 
very  little  compared  with 
that  of  the  mother,  but 
under  some  circumstances 
great  interest  may  attach  to 
the  birth  of  a  hving  child, 
even  if  it  is  predestined  not 
to  survive.  After  puncture 
the  case  may  be  left  to 
nature,  or  we  may  by  press- 
ing from  above  help  to  push 
the  head  through  the  pelvis.  If  necessary,  it  may  be  pulled  out  with 
forceps,  cranioclast,  or  cephalotribe. 

If  the  lower  uterine  segment  is  not  too  much  expanded,  we  may 
also,  after  having  diminished  the  head  by  aspiration,  perform  version 
and  extract. 

In  breech  presentation  the  aspiration  is  performed  behind  the  ear 
in  the  large  posterior  side  fontanelle. 


Skeleton  of   hydrocephalic    foetus.    (Wood's  Museum, 
Belle vue  Hospital,  No.  1237.) 


EXCESSIVE   SIZE   OF   FCETUS. 


401 


§  3.  Other  Cephalic  Enlargements. — Encephalocele,  a  tumor 
formed  by  part  of  the  brain  protruding  through  an  opening  in  the 
skull  and  covered  with  skin,  is  most  frequently  found  on  the  occiput 
or  at  the  orbit,  less  often  in  connection  with  the  vertex.  It  may  form 
a  swelling  large  enough  to  impede  delivery. 

Epignathus. — Rudiments  of  a  second  foetus  may  form  a  tumor 
hanging  out  of  the  mouth,  which  is  called  an  epignathus. 

FcETUs  IN  F(ETU. — A  rudimentary  second  foetus  may  also  be  cm- 
bedded  in  the  head  and  cause  its  enlargement. 

Elephantiasis  congenita  cystica  has  been  observed  in  a  unique 
case.     It  formed  a  helmet-like  swelling  of  the  head  (Fig.  316). 

§  4.  Abdominal  Enlargement. — More  frequently  than  the  head, 
the  enlarged  abdomen  gives  rise  to  dystocia. 

Ascites  is  not  rare.  It  may  be  found 
in  a  macerated  foetus,  or  in  consequence 
of  liver  disease  or  syphilis. 

Diagnosis. — Whether    the    head    or 

Fig.  317. 


Fig.  316. 


Congenital  cystic  elephantiasis. 

(Steinwirker). 


Foetus  with  distended  bladder.    (Hecker.) 


the  breech  precedes,  the  fetal  abdomen  is  arrested.  It  may  not  be 
distinguished  from  an  overfilled  bladder.  The  fluid  should  therefore 
be  drawn  with  an  aspirator  or  small  trocar. 

Peritonitis  may  also  cause  swelling  and  the  accumulation  of  fluid 
in  the  abdominal  cavity. 

Carcinoma  of  the  liver,  cystic  degeneration  of  the  kidneys, 
fibrocystic    degeneration    of    the    undescended    testicles,    hydrone- 

26 


402 


ABNORMAL   LABOR. 


PHROsis,  and  distended  bladder  (Fig.  317)  have  all  formed  tumors 
that  have  caused  difficulties  in  labor. 

§  5.  Other  Swellings. — Hydrothorax  is  much  rarer  than  ascites, 
but  has  also  been  found  forming  an  obstacle  to  delivery. 

Hydrorrhachis,  or  spina  bifida,  may  form  so  large  a  swelling  that 
considerable  difficulty  arises  (Fig.  318). 

QEdema,  emphysema,  and  tympanites  may  all  develop  during  labor 
and  cause  difficulty.  Even  a  large  aneurism  of.  the  aorta  and 
swelling  due  to  lymphectasia  have  impeded  delivery. 


Fig.  319. 


Fig.  318. 


Spina  bifida.    (Zweifel.) 


Hemicephalus,  oranencephalus.  (Wood's 
Museum,  Bellevue  Hospital,  No.  1243.)  One- 
third  actual  size. 


FcETUS  IN  F(etu. — One  foetus  developing  in  the  body  of  the  other 
may  form  a  tumor. 

Treatment. — As  to  treatment  much  must  be  left  to  the  judgment  of 
the  accoucheur.  We  can  only  say  in  general  that  he  should  be  as 
conservative  as  possible.  Often  a  tumor  may  be  pushed  back  into  the 
corner  of  the  pelvis,  where  there  is  more  room.  When  it  is  cystic 
and  diminution  of  its  size  is  necessary,  we  should  use  an  aspirator  or 


TWIN   LABOR.  403 

a  fine  trocar,  that  will  not  kill  the  foetus  or  cause  much  injury.  But 
if  the  swelling  is  solid  and  of  large  size,  recourse  must  be  had  to 
embryotomy. 

Hemicephali,  or  anencephali,  are  monstrosities  in  which  the  brain 
and  skull  are  nearly  absent  (Fig.  319).  On  the  other  hand,  the  body 
is  usually  stout.  These  monsters  often  present  by  the  face.  Their 
broad  shoulders  may  make  engagement  difficult. 

The  diagnosis  can  sometimes  be  made  by  feeUng  the  absence  of 
the  skull  through  the  abdominal  wall.  By  vaginal  examination  the 
sharp,  bony  edge  surrounding  the  top  of  the  head  may  be  felt.  Deliv- 
ery should  be  accomplished  in  the  way  that  will  interfere  least  with 
the  mother.  Turning  will  probably  be  the  simplest,  and  if  there  is 
any  resistance  to  extraction,  the  accoucheur  should  at  once  resort  to 
crushing. 


CHAPTER   V. 
TWIN    LABOR. 


In  cases  of  multiple  fetation  labor  is  apt  to  come  on  prematurely, 
and  when  once  the  lower  part  of  the  cervix  is  expanded  and  the  os 
has  begun  to  dilate,  nothing  can  prevent  the  continuation  of  labor. 

The  abdomen  is  unusually  distended,  in  consequence  of  which 
uterine  contractions  are  weak.  The  stage  of  chlatation  is  therefore 
slow.  During  that  of  expulsion  pressure  is  exercised  through  the 
liquor  amnii  of  the  second  ovum  and  therefore  less  effective  than 
when  it  is  applied  immediately  to  the  foetus. 

We  have  seen  above  that  the  twins  may  be  found  in  a  single  or 
a  double  ovum.  The  foetuses  may  be  placed  differently.  In  about 
half  the  cases  both  are  in  vertex  presentation  (Fig.  320).  In  one- 
third  the  first  presents  by  the  vertex  and  the  second  by  the  breech 
(Fig.  321).  A  double  breech  presentation  is  found  only  in  9  per 
cent.  Still  more  rarely  the  first  foetus  is  placed  longitudinally,  vertex 
or  breech  pointing  downward,  and  the  second  transversely,  ,or  both 
may  be  in  transverse  presentation,  which  is  the  rarest  of  all  com- 
binations. 

As  a  rule,  one  bag  of  waters  forms  at  a  time,  but  in  exceptional 
cases  two  bags  have  been  felt  at  once. 

In  the  vast  majority  of  cases  labor  takes  place  in  the  same  way 
as  in  those  where  there  is  only  one  child.  After  the  expulsion  of 
the  first  child,  there  is  a  lull  in  the  uterine  contractions,  a  new  bag 
of  waters  is  formed,  and  the  second  child  is  born  ten  or  fifteen  minutes 
after  the  other,  or  at  least  within  thirty  minutes.  In  rare  cases  the 
interval  may  extend  over  hours  or  even  several  days.      If  the  first 


404 


ABNORMAL   LABOR. 


labor  was  premature  or  an  abortion,  months  may  elapse  before  the 
second  twin  is  born. 

After  the  birth  of  the  first  child,  the  second  may  change  its 
presentation.  If  it  was  placed  transversely,  it  may  change  to  longi- 
tudinal presentation,  but  the  inverse  may  also  occur,  and  a  previously 
longitudinal  presentation  be  converted  into  a  transverse. 

The  placentae  may,  as  we  know,  be  more  or  less  grown  together, 

Fig.  320. 


Twins  in  vertex  presentation.      (Tarnier  and  Chantreuil,  1.  e.) 


but  even  then  the  whole  surface  occupied  is  larger  than  in  ordinary 
labors,  and  this  is  so  much  more  the  case  if  they  are  separate. 
Then  there  is  danger  of  one  coming  so  low  down  that  during  the 
stage  of  dilatation  it  becomes  loosened  and  causes  hemorrhage. 

In  general,  both  placentse  are  retained  till  both  children  have 
been  born.  But  when  the  first  child  is  born,  sometimes  the  second 
placenta  is  expelled  ahead  of  the  second  child,  which  soon  would  die 
from  loss  of  blood,  if  we  did  not  come  to  its  help  by  extracting  it. 


TWIN   LABOR. 


405 


Even  after  the  expulsion  of  both  placentae  there  is  a  tendency  to 
hemorrhage,  wherefore  twin  births  demand  special  watchfulness. 

Diagnosis. — While  the  diagnosis  of  twin  pregnancy  before  labor 
begins,  as  we  have  seen,  is  by  no  means  easy,  during  labor  it  becomes 
an  easy  matter.  The  small  size  of  the  presenting  part  in  comparison 
with  the  large  abdomen  may  already  awaken  the  suspicion  that  we 
have  to  deal  with  twins.     It  becomes  sure  when  we  feel  two  bags 


Fig.  321. 


Twins,  one  in  vertex  the  other  in  breech  presentation.    (Tarnier  and  Chantreuil,  1.  e.) 

of  waters  or  two  umbilical  cords,  or  a  soft  macerated  foetus  or  a 
pulseless  cord  together  with  a  beating  heart. 

When  the  first  child  is  born,  one  has  only  to  feel  through  the 
abdominal  wall  in  order  to  ascertain  the  presence  of  a  second  child 
with  a  bony  skeleton,  which  gives  an  entirely  different  sensation  from 
that  imparted  by  the  muscular  uterus  and  soft,  pulpy  placenta.  By 
vaginal  examination  we  may  feel  a  second  bag  of  waters  and  the  pre- 
senting part  of  the  foetus. 

Prognosis. — For  the  mother  the  prognosis  is  upon  the  whole  good. 


406 


ABNORMAL   LABOR. 


There  may,  however,  sometimes  be  the  drawback  of  a  tedious  labor, 
the  necessity  of  operative  interference,  and,  consequently,  greater 
danger  of  puerperal  infection.  There  is  also  some  danger  of  hemor- 
rhage from  the  placenta,  either  during  or  after  labor. 

For  the  child  the  prognosis  is  much  less  good.  The  children  are 
smaller  than  an  average  single  child.  Labor  often  comes  on  before 
they  have  been  carried  the  normal  length  of  time.  In  nearly  half  the 
cases  the  second  child  is  in  an  abnormal  presentation.  One  child  may 
be  in  the  way  of  the  other  during  labor.  Often  some  kind  of  conserva- 
tive operation  is  needed  to  end  labor,  and  sometimes  destructive  oper- 
ations become  necessary.  Finally,  the  mother  has  rarely  milk  enough 
for  two  children,  so  that  they  have  to  be  fed  artificially. 

Treatment. — When  the  accoucheur  discovers  the  presence  of  a 
second  child,  he  should  inform  the  friends  of  the  condition,  but  not 
the  mother,  as  it  might  cause  undesirable  excitement. 

Under  ordinary  circumstances  the  conduct  of  labor  is  the  same 
as  in  single  labors.  Only  greater  vigilance  is  required,  especially  with 
regard  to  hemorrhage  or  collision  between  the  children,  since  timely 
interference  may  avoid  great  evil. 

On  account  of  possible  connection. between  the  two  placentse,  the 

proximal  end  of  the  cord  should 
invariably  be  tied,  as  otherwise 
the  second  child  might  bleed  to 
death. 

As  twins  are  sometimes  so 
like  each  other  that  they  cannot 
be  distinguished,  it  is  advisable 
to  tie  a  ribbon  around  the  wrist 
of  the  first-born  child. 

When  the  second  bag  of 
waters  is  formed,  it  is  best  to 
rupture  it,  as  the  canal  has  been 
fully  dilated  by  the  passage  of 
the  first  child.  If  any  danger 
menaces  mother  or  child,  the 
second  child  should  at  once  be 
extracted,  with  or  without  turn- 
ing. Otherwise  it  is  better  to 
wait  and  give  the  uterus  full 
time  to  contract  well  so  as  not  to  risk  post-partum  hemorrhage.  It 
is  well  to  tie  a  binder  tightly  around  the  abdomen,  or  still  better  to 
hold  the  uterus  with  the  hand.  Even  after  the  birth  of  the  second 
child  and  both  placentse,  the  uterus  should  be  watched  on  account  of 
the  tendency  to  hemorrhage. 


Locked  twins,  both  in  head  presentation. 
(R.  Barnes.) 


TWIN    LABOR. 


407 


If  the  first  foetus  is  in  breech  presentation,  it  is  quite  common  that 
some  assistance  is  rec|uirecl  in  dehvering  the  head,  since  the  uterine 
contractions  work  under  a  disadvantage. 

If  help  is  needed  in  delivering  the  second  child,  as  a  rule  version 
and  extraction  are  indicated ;  but  if  the  head  is  in  the  pelvic  cavity, 
it  should  be  extracted  with  forceps. 

If  both  foetuses  present  at  the  same  time — so-called  locked  twins — 
assistance  is  called  for.  If  both  heads  present,  we  try  to  push  one 
up  and  pull  the  other  down  with  forceps.  If  this  does  not  succeed, 
the  upper  head  must  be  perforated. 

The  head  of  the  second  foetus  may  be  lodged  between  the  chin 
and  thorax  of  the  second  (Fig.  322).  One  may,  perhaps,  disentangle 
the  heads  by  external  and  internal  manipulations.  Failing  this,  one 
may  seize  the  foremost  head 
with  the  forceps,  and  wdiilst 
an  assistant  pushes  away 
the  second  head  the  first 
child  may,  perhaps,  be  ex- 
tracted. 

If  head  and  breech  try  to 
enter  the  pelvis  at  once,  the 
breech  should  be  pushed 
up  and  forceps  applied  to 
the  head. 

If  the  lower  foetus  is  in 
breech  presentation  and  the 
second  presents  by  the 
head,  we  try  first  to  push 
the  head  out  of  the  way, 
and,  if  that  does  not  suc- 
ceed, to  pull  it  through  by 
applying  forceps. 

But  the  second  child's 
head  may  again  be  lodged 
between  the  chin  and  chest 
of  the  partly  born  child 
(Fig.  323),  the  two  heads 
forming  a  wedge,  the  base 
of  which  cannot  pass  the 
brim  of  the  pelvis.  Then 
the  first  child  must  be  sac- 
rificed, which  is  so  much  more  readily  decided  upon  as  in  all  likeli- 
hood it  will  by  this  time  be  dead.  The  neck  should  be  severed  with 
scissors  or  a  wire  ecraseur  and  the  head  pushed  up  into  the  abdomen. 


Locked  twins,  first  child  partly  born  in  breech  presen- 
tation, the  second  lodged  with  the  face  under  the  chin  of 
the  first.    (R.Barnes.) 


408 


ABNORMAL   LABOR. 


If  both  foetuses  present  by  the  breech,  the  accoucheur  should  push 
up  the  upper  and  extract  the  lower. 

Sometimes  all  four  feet  may  present.  Then  we  "should  extract 
one  child  first  by  its  feet,  but  before  so  doing  we  must  make  a  care- 
ful examination  so  as  to  avoid  pulling  on  extremities  belonging  to 
two  different  children.  If  a  foot  or  a  hand  presents  with  the  head,  we 
should  try  to  push  it  up. 


CHAPTER   VI. 

DOUBLE   MONSTROSITIES. 

When  one  germ  by  fission  gives  rise  to  the  formation  of  two 
bodies,  these  may  become  entirely  separated,  and  each  form  a  perfect 
body.      Then  they  are  simply  twins  contained  in  one  ovum.     But 

Fig.  324. 


Dicephalus.     (Zweifel.) 


sometimes  the  process  of  fission  is  imperfect,  and  the  result  is  that 
the  two  bodies  remain  more  or  less  united,  and  in  most  cases  sym- 
metrical parts  of  the  bodies  are  missing  (Fig.  324). 


DOUBLE   MONSTROSITIES. 


409 


In  the  conjoined  Chinese  twins,  Eng  and  Chang,  from  their  birth- 
place known  as  the  Siamese  tiinns,  the  separation  was  perfect,  except 
that  a  narrow  band  extended  from  one  sternum  to  the  other.  The 
two  men  so  curiously  linked  together  were  both  married  and  lived 
till  the  age  of  sixty-three  years.  They  wanted  to  be  separated,  but  no 
surgeon  could  be  found  willing  to  do  so.  Finally  they  died,  with  an 
hour's  interval,  in  1874. 

Fig.  325. 


Thoracopagi  dissected.  (Wood's  Museum.  Bellevue  Hospital,  No.  1257.)  Length  of  bodies  six- 
teen inches  (forty-one  centimetres),  a,  .single  liver;  b,  right  thymus;  c,  right  heart;;  dd',  right 
lungs  :  e,  right  pancreas  ;  /,  right  stomach  ;  [/,  right  intestine  ;  h,  left  heart;;  ii',  left  lungs;  j,  left 
stomach  ;  k,  left  intestine. 

In  1900  the  Brazilian  conjoined  twins,  Rosalina  and  Maria,  also 
thoracopagae,  w^ere  separated  by  Dr.  Chapot-Prevost,  of  Rio  Janeiro, 
one  dying  from  pleurisy,  the  other  surviving ;  and  in  1 902  the  Hin- 
doo thoracopagge,  Radica  and  Dordica,  were  separated  by  Dr.  Doyen, 
of  Paris.  Both  were  tuberculous,  and  one  died  a  few  days  after  the 
operation. 

In  the  pair  represented  in  Fig.  325  only  the  liver  was  common  for 
the  two  bodies :  all  other  organs  were  double. 


410  ABNORMAL    LABOR. 

Double  monstrosities  are  not  very  rare  :  specimens  of  them  are 
found  in  most  obstetrical  museums ;  but  they  are  rarely  born  alive 
and  still  more  rarely  do  they  survive.  The  Hungarian  sisters,  Helen 
and  Judith,  were  united  by  the  back,  and  lived  twenty-three  years. 
I  have  seen  a  similar  formation  in  two  grown-up  conjoined  negro 
girls,  called  Ilillie  and  Christine,  and  a  double  white  baby  called  Rose- 
Marie,  who  had  one  body  from  the  pelvis  down,  while  above  the 
pelvis  the  bodies  separated  nearly  at  right  angles  (Fig.  326). 

Some  women  have  repeatedly  borne  double  monstrosities,  and 
sometimes  hereditary  influence  seems  to  play  a  role.  Such  mon- 
strosities may  be  born  without  any  skilled  assistance,  and  were  so  in 
twenty  out  of  thirty-one  cases  collected  by  Playfair.     Most  of  them 

Fig.  326. 


Rose-Marie,  dicephalus. 

present  by  the  pelvic  end,  which  greatly  facilitates  their  birth.  But 
in  some  cases  delivery  is  exceedingly  difficult.  Still,  upon  the  whole, 
the  prognosis  is  good  for  the  mother. 

From  an  obstetric  stand-point  we  may  distinguish  four  classes  of 
such  cases. 

A.  The  two  bodies  may  be  united  in  front, — thoi^acopagi  (Fig. 
327), — to  which  class  the  Siamese  twins  belonged,  and  which  is  the 
most  common.  Nature  usually  ends  these  cases  by  expelling  all  the 
feet  first,  and  that  is  therefore  the  way  to  be  imitated.  If  possible, 
all  four  legs  should  be  brought  down  and  the  posterior  head  deliv- 
ered first  by  pulling  the  body  of  the  child  strongly  up  over  the  abdo- 
men of  the  mother.  Last  comes  the  second  head.  The  backs  should 
be  kept  in  an  oblicjue  diameter,  as  this  is  longer  than  the  anteropos- 
terior and  offers  the  advantage  that  the  bodies  are  not  so  likely  to  be 
arrested  by  the  promontory  and  symphysis.  In  a  case  of  this  kind 
delivery  Avas  accomplished  by  cutting  off  one-half  of  the  anterior  body. 


DOUBLE   MONSTROSITIES. 


411 


If  the  heads  present  first  one  head  is  born ;  then  comes  the  body 
by  a  process  of  spontaneous  evolution ;  and  last  the  second  child 
is  born,  probably  footling,  which  is  possible  on  account  of  the  great 
mobility  there  always  is  between  the  two  bodies  in  this  class — a  mo- 
bility which  allows  the  accoucheur  to  turn  the  bodies  so  that  the  head 

end  of  one  lies  in  contact  with  the  foot 
^'^-  ^27.  end  of  the  other. 

A  rarer  mechanism  of  labor  with 
head  presentation  is  that  one  head  fol- 


Ficx.  328. 


Thoracopagi.     (Olshausen-Veit  ^ 


Helen  and  Judith,  ischiopagse. 


lows  the  other,  being  pressed  against  its  neck.  This  has  also  suc- 
cessfully been  imitated,  each  head  being  pulled  out  with  forceps  and 
the  bodies  then  pulled  out  simultaneously.  But  it  is  evident  that  this 
mode  is  only  possible  if  the  foetuses  are  unusually  small  or  the  pelvis 
exceptionally  large. 

Sometimes  room  may  be  gained  by  decapitating  the  first  head, 
and  then  turn  and  extract. 

The  diagnosis  is  very  difficult.  External  manipulation  and  com- 
mon vaginal  examination  give  no  information.  As  a  rule,  the  case  is 
taken  for  one  of  common  twins  until  labor  is  arrested.  The  true 
nature  of  the  case  can  be  found  only  by  anaesthetizing  the  patient  and 
introducing  the  hand  far  enough  to  feel  the  place  of  union  between 
the  two  foE'tuses. 

B.  The  second  class  comprises  those  double  monstrosities  which 


412  ABNORMAL    LABOR. 

are  united  by  the  back,  especially  the  pelvis, — ischiopagi, — to  which 
Helen  and  Judith  belonged  (Fig.  328).  Delivery  is  probably  still  more 
difficult  than  in  the  former  class,  the  area  of  junction  being  less  yield- 
ing. The  treatment  is  the  same,  namely,  to  bring  down  all  four  legs 
or  to  extract  one  head  after  the  other. 

C.  The  third  class  is  composed  of  double  monstrosities  which  have 
two  heads  and  more  or  less  of  the  upper  part  of  the  body  double  and 
only  one  lower  part  of  body, — dicephali  (Fig.  324),  In  the  natural 
mode  of  dehvery  first  one  head  is  born,  then  follows  the  body  by 
spontaneous  evolution,  and  last  comes  the  second  head.  If  this 
does  not  take  place,  the  first  head  should  be  decapitated,  and  the  feet 
brought  down,  when  the  delivery  of  the  second  head  becomes  easy. 

If  exceptionally  the  feet  come  down  first,  the  case  is  treated  as  in 
the  first  class, — that  is  to  say,  by  pulling  the  body  well  up  over  the 
abdomen  of  the  mother. 

D.  In  the  fourth  class  the  heads  are  united,  the  bodies  separated, 
— craniopagi.  Here  the  difficulty  is  caused  by  the  size  of  the  head, 
and  assistance  is  given  by  perforating  and  crushing  it,  whether  it  pre- 
sents or  comes  last. 

"With  all  monstrosities  we  should  not  hesitate  to  mutilate,  if  any- 
thing is  gained  by  it,  and  under  no  circumstance  should  the  mother  be 
exposed  to  the  dangers  of  Caesarean  section. 


CHAPTER   VII. 
ABNORMALITIES  OF  THE  OVUM. 

§  1.  Abnormal  Membranes. — Too  Thin  Membranes. — If  the  mem- 
branes of  the  ovum  are  too  thin  and  friable,  the  bag  of  waters  ruptures 
prematurely,  whereby  the  mother  suffers  more  pain  than  when  the 
cervix  and  os  are  being  gradually  expanded  by  the  elastic  membranes. 
There  is  also  greater  danger  of  infection  taking  place,  especially  if 
many  vaginal  examinations  are  made.  The  child  is  exposed  to  a 
pressure  that  may  interfere  with  circulation  and  respiration  or  give 
rise  to  prolapse  of  the  cord,  and  if  all  the  water  drains  off, — a  so- 
called  dri/  birth, — the  necessary  movements  of  the  child  during  expul- 
sion may  be  impeded. 

But  the  beginner  should  not  form  an  exaggerated  opinion  of  the 
importance  of  the  premature  rupture  of  the  membranes.  Most  of  the 
time  it  has  no  appreciable  effect,  the  cervix  closing  in  on  the  present- 
ing head.  Sufficient  liquor  amnii  is  retained.  The  patient  should, 
however,  be  kept  in  bed  and  defecation  made  easy  by  the  administra- 
tion of  a  mild  aperient,  like  Hunyadi  Janos  water. 


ABNORMALITIES    OF   THE    OVUM.  413 

Membranes  too  Resistant. — 11",  on  the  other  hand,  the  membranes 
are  too  tough  and  resistant,  they  do  not  rupture  when  the  cervix  is 
dilated.  Thus  the  force  developed  by  the  contracting  uterus  is  partly 
lost,  and  the  whole  ovum,  as  we  have  seen,  may  be  expelled 
unruptured. 

When  the  os  is  fully  dilated,  the  accoucheur  should  rupture  the 
membranes.  This  may  be  done  by  seizing  them  in  the  interval 
between  two  contractions  and  tearing  them,  or  more  easily  during  a 
labor-pain  by  pricking  them  with  the  stylet  of  a  catheter  or  a  sharpened 
goose-quill.  In  performing  this  little  operation  the  accoucheur  should, 
however,  be  careful  not  to  enter  more  deeply  than  necessary,  as  other- 
wise he  might  injure  the  foBtus.  For  cleanliness  it  is  well  to  place  a 
bedpan  under  the  patient,  into  which  the  expelled  hc^uor  amnii  will  flow. 

If  the  child  is  born  in  the  ovum,  this  should  be  torn  in  order  to 
admit  air  to  the  lungs. 

Adherent  Membranes. — In  normal  labor  separation  between  the 
uterus  and  the  ovum  takes  place  in  the  ampullar  layer  of  the  decidua. 
But  if  there  has  been  endometritis  before  or  during  pregnancy,  the 
decidua  is  too  thick  and  resistant,  and  the  chorion  adheres  more  or 
less  to  it.  Then  the  separation  takes  place  between  the  chorion  and 
the  amnion,  and  the  chorion  and  decidua  are  retained,  which  may 
give  rise  to  hemorrhage.  If  this  occurs  the  accoucheur  should  intro- 
duce his  whole  hand  into  the  uterus  and  scrape  off  the  retained  mem- 
branes with  his  finger-nails,  and  then  give  an  intra-uterine  douche, 
preferably  with  creolin  on  account  of  its  combined  antiseptic  and 
haemostatic  properties. 

If  there  is  no  hemorrhage,  but  a  large  piece  of  the  membranes  is 
retained,  then  it  is  well  to  tie  a  silk  thread  to  it,  and  leave  it  until  the 
following  day,  when  by  pulling  on  the  string  the  shred  is  easily 
removed.     The  smaller  shreds  are  discharged  with  the  lochia. 

§  2.  Abnorraalities  of  the  Umbilical  Cord. — Coiling. — We  have 
seen  that  during  pregnancy  the  cord  may  be  wound  around  the  body 
of  the  foetus.  It  may  also  lie  coiled  up  in  front  of  the  presenting 
part,  and  during  labor  the  child  may  be  pushed  through  one  or  more 
circumvolutions.  In  this  way  a  cord  that  really  is  too  long  may  be- 
come relatively  too  short  and  prevent  the  proper  movements  of  the 
foetus  during  labor.  It  is  quite  frequently  twisted  once  or  twice 
around  the  neck,  which  exposes  the  child  to  strangulation.  When 
this  is  the  case,  the  accoucheur  tries  to  loosen  the  string  and  to  pull 
it  over  the  head  or  let  the  child  glide  out  through  the  loop.  In  breech 
presentation  it  may  descend  between  the  legs  and  extend  over  the 
back.  Then  the  loosened  loop  should  be  pushed  over  one  of  the  but- 
tocks. But  if  the  cord  does  not  yield  so  as  to  allow  these  displace- 
ments, it  should  be  cut  and  both  ends  tied. 


414  ABNORMAL   LABOR. 

Shortness  of  Cord. — If  the  cord  is  so  short  that  it  interferes  with 
the  free  movement  necessary  in  labor,  it  may  be  torn  off  near  the 
body  of  the  foetus,  which  may  bleed  to  death  while  still  in  the  uterus. 
Or  if  the  cord  holds  it  may  pull  off  the  placenta  from  the  uterus  and 
cause  hemorrhage  and  asphyxiation  in  that  way.  Or  if  also  the 
placenta  resists,  the  uterus  may  become  inverted  or  the  birth  of  the 
child  may  be  prevented. 

The  diagnosis  during  pregnancy  is  impossible  and  during  labor 
difficult.  We  maybe  brought  to  think  of  this  condition  if  the  meco- 
nium is  expelled  or  the  heart-beat  becomes  slow.  If  the  cord  can  be 
reached,  it  may  be  felt  tense,  and  should  then  be  cut  at  once,  and  the 
foetus  extracted. 

Prolapse  of  the  Cord. — The  umbilical  cord  may  present  at  the 
brim  below  or  with  the  other  presenting  part  before  the  membranes 
rupture,  and  it  may,  after  the  waters  have  broken,  sink  down  into  the 
vagina  or  even  outside  of  the  vulva,  while  in  other  cases  only  a  small 
loop  is  found  outside  the  os. 

The  frequency  with  which  this  unfortunate  accident  occurs,  seems, 
like  that  of  face  presentations,  to  vary  much  in  different  countries. 
In  France  it  was  only  observed  in  1  case  of  each  446,  in  England  in  1 
out  of  207,  and  in  Germany  in  1  out  of  156.  Maybe  the  usual  posture 
used  in  delivering  women  has  some  influence  :  in  France  they  place 
the  woman  on  her  back  with  somewhat  elevated  pelvis,  in  England 
they  use  the  lateral  posture,  and  in  Germany  they  prefer  the  dorsal 
position  with  elevated  shoulders,  which  would  certainly  promote  pro- 
lapse of  the  cord.  But  perhaps  the  relative  frequency  of  contracted 
pelves  accounts  for  a  corresponding  frequency  of  prolapse  cases. 

Etiology. — The  chief  factor  that  causes  presentation  and  prolapse 
of  the  cord  is  a  deficient  adaptation  between  the  presenting  part  and 
the  brim  of  the  pelvis.  They  occur,  therefore,  in  contracted,  espec- 
ially flat,  pelves.  They  are  much  more  frequent  with  abnormal  pre- 
sentations, especially  transverse,  face,  and  foot  presentations,  than 
with  vertex  presentation.  Flaccidity  of  the  lower  uterine  segment 
will  give  rise  to  a  less  perfect  adaptation  between  the  uterus  and  the 
presenting  part,  and  we  find  also  that  the  accident  is  much  more  com- 
mon in  pluriparae  than  in  primiparge.  The  longer  the  cord  is,  the 
greater  is  cceteris paribus  the  chance  of  its  prolapsing.  A  large  amount 
of  liquor  amnii  and  its  sudden  discharge  will  be  apt  to  wash  the  cord 
down.  A  premature  rupture  of  the  membranes  and  a  prolonged 
partial  opening  of  the  os  naturally  increase  the  danger  of  a  prolapse 
occurring.  A  low  insertion  of  the  placenta  M'ill  also  favor  it.  With 
a  vertex  presentation  it  can  only  happen  at  the  time  of  rupture  or 
shortly  after.  When  first  the  head  is  well  engaged,  there  is  no  space 
left  for  the  prolapse  to  take  place  in. 


ABNORMALITIES    OF    THE    OVUM.  415 

Diagnosis. — Before  the  waters  break  it  is  not  always  easy  to  recog- 
nize a  presenting  cord.  Still,  in  an  interval  between  pains,  when  the 
bag  relaxes,  we  may  feel  the  movable,  soft,  finger-thick  string  and  its 
pulsation.  When  the  membranes  have  ruptured,  a  small  loop  high  up 
in  the  vagina  may  be  overlooked,  but  if  the  fetal  heart-sounds  grow 
weak  and  slow,  the  accoucheur  should  bear  in  mind  the  possibility 
of  its  presence  and  feel  for  it.  When  a  larger  loop  descends  into 
the  vagina,  it  obtrudes  itself  on  the  examining  fmger  and  cannot  be 
taken  for  anything  else. 

Prognosis.- — The  prognosis  for  the  mother  is  good,  but  that  for 
the  child  is  so  much  the  worse.  For  it  prolapse  of  the  cord  is  one 
of  the  most  dangerous  complications  of  childbirth.  According  to 
statistics  over  one-half  of  the  children  die.  The  mortality  is  greater 
in  primiparae  than  in  pluriparae,  which  can  easily  be  accounted  for 
by  the  more  tedious  labor  and  the  greater  firmness  of  the  soft  parts 
of  the  parturient  canal.  If  prolapse  of  the  cord  is  comparatively  rare 
with  vertex  presentation,  on  the  other  hand  it  is  much  more  dangerous 
than  with  other  presentations,  the  cord  being  more  apt  to  be  squeezed 
between  the  hard  skull  and  the  pelvis.  The  breech  is  softer,  and  with 
a  transverse  presentation  or  a  foot  presentation  there  is  hardly  any 
danger.  With  vertex  presentation  the  infantile  mortality  reaches  the 
terrible  number  of  64  per  cent. 

The  great  danger  in  prolapse  of  the  cord  arises  mainly  from  com- 
pression, which,  as  we  have  seen  in  speaking  of  delivery  in  pelvic 
presentations,  leads,  in  a  very  short  time,  to  asphyxia  and  death  of 
the  child. 

Treatment. — The  diagnosis  once  made,  the  patient  cannot  be  left 
a  moment  alone.  She  and  her  child  have  to  be  watched  constantly, 
since,  when  the  time  for  action  has  come,  delay  means  the  death  of  the 
latter.  We  must  distinguish  three  different  conditions,  each  calling 
for  different  assistance, — the  time  before  the  rupture  of  the  membranes, 
the  time  after  rupture  of  the  membranes  with  a  not  fully  dilated  os, 
and  the  time  after  full  dilatation  has  been  accomplished. 

As  long  as  the  membranes  are  unruptured,  there  is  little  or  no 
danger,  and,  on  the  other  hand,  it  is  of  the  greatest  importance  to 
preserve  them  till  full  dilatation  is  established.  To  try  to  push  the  cord 
aside  is  of  little  avail,  since  in  all  likelihood  it  will  fall  down  again,  and 
we  run  the  risk  of  rupturing  the  membranes  by  our  manipulations, 
which  would  make  the  situation  worse.  We  may  place  the  patient  in 
the  elevated-pelvis  position  on  her  back,  and  whether  the  cord  slides 
away  or  not,  we  may  then  place  the  patient  on  the  side  where  the  pro- 
lapse was,  the  effect  of  which  is  to  tip  the  fundus  down  on  this  side 
and  the  lower  uterine  segment  over  to  the  other  side,  so  that  there  is 
less  pressure  on  this  side  in  case  the  cord  falls  down  again.  The  position 


416  ABNORMAL   LABOR. 

on  the  back  with  the  head  low  cannot  be  sustained  very  long,  unless 
the  patient  is  ansesthetized,  which  is  not  desirable,  since  we  want 
labor-pains  to  dilate  the  os.  If  the  cord  slides  up  into  the  cavity  of 
the  uterus,  we  may  by  pressure  from  above  try  to  press  the  head  into 
the  brim  and  thus  prevent  the  prolapse  from  being  reproduced.  In 
order  to  further  dilatation  a  colneurynter  maybe  placed  in  the  vagina, 
which  protects  the  membranes,  but  if  stethoscopy  shows  that  the  cord 
is  being  compressed,  the  colpeurynter  should  be  removed. 

If  the  OS  is  not  sufficiently  dilated  to  end  labor  with  forceps  or 
version,  but  the  waters  have  broken,  the  patient  should  be  placed  in 
the  elevated-pelvis  position  and  the  cord  replaced  with  a  suitable 
instrument,  such  as  represented  in  Fig.  329. 

Fig.  329. 


Repositor  for  prolapsed  umbilical  cord. 

I  found  it  in  an  instrument-maker's  store,  but  could  not  ascertain 
the  inventor's  name.  All  the  people  remembered  was  that  it  had 
originated  with  a  California  doctor. 

The  instrument  consists  of  a  rather  stiff  flexible  tube  through 
which  runs  a  whalebone  stylet  with  handle.  At  the  other  end  is  a 
bit  of  ribbon  with  a  button  that  fits  into  the  end  of  the  tube.  The 
ribbon  is  carried  around  the  prolapsed  cord,  the  button  pushed  into 
the  tube,  and  this  together  with  the  cord  brought  all  the  way  up  to 
the  fundus,  where  it  may  be  kept  till  after  the  birth  of  the  child,  but 
if  it  is  sure  that  the  cord  cannot  again  prolapse,  it  may  also  be 
withdrawn  after  releasing  the  ribbon  by  pushing  the  button  out  by 
means  of  the  whalebone  staff. 

The  position  with  elevated  pelvis  facilitates  the  replacement  very 
much. 

Where  no  operating-table  with  facilities  for  elevating  the  pelvis 
is  available,  we  may  improvise  one  by  using  a  chair  as  we  did  to  raise 
the  shoulders  (Fig.  222,  p.  191),  but  now  the  chair  is  placed  under  the 
pelvis  and  the  feet  are  bent  over  the  round  (Fig.  330). 

Or  else  the  patient  may  be  placed  on  a  padded  ironing-board,  the 
lower  end  of  which  is  raised  and  fastened  to  the  foot  of  the  bed  or  a 
chair.^  The  elevated-pelvis  position  has  the  advantage  over  the  knee- 
chest  position,  which  generally  is  recommended,  that  the  patient  can 

1  The  elevated-pelvis  position  is  mostly  known  in  this  country  as  Trendelen- 
burg's position,  from  the  name  of  the  surgeon  who  has  contributed  most  to  popularize 
it,  but  it  was  used  and  described  years  before  by  Bardenheuer,  of  Cologne,  in  his 
work,  "Drainage  der  Peritoneal  Hohle,"  Stuttgart,  1881.  In  Germany  it  is  called 
Beckenhochlage. 


-  ABNORMALITIES   OF   THE    OVUM.  417 

be  kept  longer  in  it  without  being  anaesthetized,  that  an  anaesthetic  can 
easily  be  administered,  and  that  it  is  more  favorable  for  performing 
version  and  extraction.  By  pulling  the  patient  so  far  out  as  to  have 
the  lower  extremities  fall  down  at  full  length  we  obtain  even  Walcher's 
Hangelage,  which  facilitates  extraction,  as  will  be  described  later.  (See' 
Operations,  Fig.  424.) 

Having  replaced  the  cord,  the  accoucheur  should  anaesthetize  the 
patient,  and  try  if  he  can  dilate  the  cervix  manually  according  to  the 
method  of  Dr.  Philander  A.  Harris.     (See  Operations,  Fig.  422.) 

The  third  eventuality,  and  that  most  frequently  met  with  in  con- 
sultation practice,  is  that  the  os  is  fully  dilated  when  the  patient  is 
seen.  Then  the  patient  should  rapidly  be  put  in  the  elevated-pelvis 
position,  and  the  accoucheur  seize  the  prolapsed  cord  with  his  whole 
hand  and,  if  possible,  carry  it  up  into  the  abdomen,  turn  and  extract. 
If  there  is  any  compression  of  the  cord,  this  should  be  done  without 
anaesthesia  in  order  to  save  time.  If  there  is  no  room  to  pass  the 
hand,  he  should  apply  the  forceps  and  extract  as  rapidly  as  possible. 

In  pelvic  presentations  one  foot  should  be  brought  down,  as 
thereby  the  breech  is  diminished,  and  the  leg  serves  as  protection  for 
the  cord  against  pressure. 

In  prolapse  with  face  presentation,  and  when  an  arm  is  prolapsed 
together  with  the  cord,  version  and  extraction  are  indicated.  In  foot 
presentation  it  would  be  useless  to  try  reposition,  since  the  prolapse 
is  immediately  reproduced,  and  there  is  not  much  danger  of  com- 
pression. 

With  cross  presentation  reposition  would  also  be  useless,  and  with 
this  presentation  there  is  no  danger  of  compression.  The  case  is 
treated  with  podalic  version  and  extraction  as  soon  as  the  os  is  suffi- 
ciently dilated.  If  there  is  no  pulsation  in  the  prolapsed  cord,  there 
is  no  call  for  any  special  treatment,  and  the  case  should  be  managed 
as  we  would  deal  with  it  were  there  no  prolapse ;  only  the  accou- 
cheur should,  in  order  to  avert  blame,  foretell  to  the  friends  that  the 
child  is  lifeless. 

§  3.  Retained  and  Adherent  Placenta. — Normally  the  placenta 
can  be  expressed  within  twenty  minutes,  but  sometimes  our  efforts  at 
expression  remain  fruitless.  The  after-birth  does  not  come  out.  This 
may  be  due  to  one  of  two  conditions  vastly  different  in  importance. 
The  placenta  may  simply  be  retained  or  it  may  be  adherent. 

The  retained  placenta  may  lie  in  the  vagina  or  in  the  uterus.  If  it 
is  in  the  vagina,  the  uterus  is  well  contracted  and  small,  and  by  insert- 
ing two  fingers  into  the  vagina  we  not  only  feel  the  placenta,  but  can 
easily  pull  it  out  by  following  the  cord  and  pressing  on  the  placenta  at 
both  sides  of  the  cord  or  by  hooking  the  two  fingers  over  the  top  of 
the  placenta. 

27 


418 


ABNORMAL   LABOR. 


The  placenta  may  have  been  cast  loose,  but  is  retained  in  the 
uterine  cavity  by  muscular  contraction,  especially  at  the  seat  of  the 
contraction  ring.  Authors  attribute  this  frequently  to  so-called  hour- 
glass contraction^  but  in  reality  the  upper  part  of  the  uterus  is,  as  a 
rule,  more  or  less  contracted,  and  the  lower  part  is  decidedly  flaccid 
(Fig.  331).  Only  the  contraction  is  irregular  and  strongest  at  the 
narrowest  part  of  the  uterus.  Retention  of  the  placenta  used  to  be 
much  more  common  when  the  mode  of  delivery  was  to  puil  on  the 
cord  or  press  directly  on  the  placenta  inside  the  uterus.     With  the 

Fig.  331. 


Retained  placenta. 

introduction  of  Crede's  expression  method  retention  has  become  a 
rare  accident.  This  indicates  the  prophylactic  treatment.  The  cura- 
tive treatment,  if  there  is  a  serious  obstruction,  consists  in  administer- 
ing chloroform  and  pressing  on  the  contracted  ring  with  the  fingers 
united  into  a  cone  around  the  thumb.  But  often  all  that  is  needed  is 
to  follow  the  cord  up  to  its  insertion,  wind  it  around  the  fingers  of 
the  left  hand,  and  press  on  the  placenta  with  the  index  and  middle 
finger  of  the  right  hand,  when  the  placenta  readily  yields. 

As  it  is  always  preferable  not  to  enter  the  uterus,  and  the  placenta 
may  come,  out  spontaneously  or  by  expression,  the  accoucheur  should 
be  in  no  hurry  about  removing  the  placenta  if  there  is  no  hem- 
orrhage. It  is  the  writer's  rule  to  wait  an  hour  before  having  re- 
course to  any  other  measures  than  repeated  compression  of  the 
fundus. 

If  the  uterus  has  been  entered,  it  ought  also  to  be  washed  out  with 
some  antiseptic  solution,  especially  lysol  or  creolin. 


.     ABNORMALITIES   OF   THE    OVUM.  419 

Adhesion  of  the  placenta  is  a  much  more  serious  matter  than  mere 
retention.  It  may  be  total  or  partial ;  in  the  latter  case  it  is  mostly 
found  at  the  periphery,  while  in  the  centre  the  connection  with  the 
uterus  may  be  normal.  The  decidua  serotina  in  the  adherent  parts 
has  been  replaced  by  tough  connective  tissue,  which  extends  deep 
into  the  muscular  coat.  This  condition  is  usually  due  to  chronic 
endometritis.  Some  women  have  an  adherent  placenta  in  several 
successive  pregnancies.  It  follows  sometimes  partial  detachment  of 
the  placenta  during  pregnancy.  The  cause  may  also  be  an  abnormal 
structure  of  the  placenta,  especially  a  membranous  placenta.  The 
adhesion  is  most  frequently  found  in  the  cornua  of  the  uterus,  the 
original  site  of  implantation  of  the  ovum,  where  the  connection  may 
have  become  more  sohd,  or  where  villi  of  the  chorion  may  have  grown 
into  the  tubes.  It  is  also  apt  to  be  found  with  placenta  prsevia, 
where  the  insertion  takes  place  over  the  os  internum. 

Prognosis. — Both  retention  and  especially  adhesion  of  the  placenta 
often  give  rise  to  hemorrhage,  which  may  prove  disastrous  to  both 
mother  and  child. 

Treatment. — The  patient  is  placed  on  a  table  and  anaesthetized,  the 
legs  drawn  up  and  the  knees  bent.  The  particularly  well-disinfected 
hand  is  carried  between  the  membranes  and  the  uterine  wall  up  to 
the  upper  margin  of  the  placenta ;  the  fmgers  are  bent  and  the  nails 
are  used  as  knives  to  sever  the  connection  between  the  placenta  and 
the  uterus,  while  this  is  steadied  from  without  with  the  other  hand. 
If  we  cannot  obtain  a  line  of  cleavage  here,  we  try  the  sides  of  the 
placenta  and  enter  where  best  we  can.  It  is  a  great  advantage  if  the 
placenta  can  be  peeled  off  in  one  piece  and  from  above  downward. 
But  where  the  connection  with  the  uterus  is  very  dense  this  is  impos- 
sible, and  we  must  be  satisfied  by  removing  it  piecemeal,  which  is 
apt  to  be  accompanied  by  much  more  hemorrhage. 

Besides  the  fingers,  the  large  dull  wire  curette  (Fig.  411)  and  a 
placenta-forceps  with  good  grip  and  broad  dull  ends  (Figs.  412,  413) 
may  be  needed.  If  necessary,  it  is  better  to  leave  a  little  of  the  pla- 
cental tissue  than  to  perforate  the  uterus.  When  as  much  as  possible 
has  been  removed,  the  uterus  is  irrigated. 

§  4.  Placenta  Praevia. — The  fertilized  ovum  may  become  embedded 
so  low  down  on  the  wall  of  the  cavity  of  the  uterus  that  the  placenta 
covers  the  internal  os,  or  at  least  that  portion  of  the  uterus  which  must 
change  its  position  in  order  to  allow  the  dilatation  of  the  os  necessary 
for  the  passage  of  the  foetus.  When  this  dilatation  takes  place,  more 
or  less  of  the  placenta  is  separated  from  its  connection  with  the  uterus, 
which  process  is  accompanied  by  hemorrhage,  and  will  be  described 
together  with  hemorrhage  from  other  sources. 


420  ABNORMAL    LABOR. 

CHAPTER   VII I. 

OBSTRUCTION'S    IX    THE    PARTURIENT    CANAL. 

§  1.  Displacements  of  the  Uterus. — Pendulous  Abdomen. — We 
have  seen  that,  as  a  rule,  anteversion  during  pregnancy  is  of  httle  im- 
portance when  there  is  an  abdominal  wall  offering  normal  resistance, 
which  makes  the  uterus  rise  to  the  proper  position.  But  if  the  ab- 
dominal wall  is  weak,  the  heavy  pregnant  uterus  falls  forward,  and  it 
may  even  tip  so  much  downward  that  the  fundus  is  in  the  neighbor- 
hood of  the  knees. 

Sometimes  there  is  only  an  unusual  flaccidity  of  the  abdominal 
wall,  but  in  other  cases  there  is  such  a  diastasis  between  the  recti 
muscles  that  the  uterus  protrudes  between  them  and  lies  directly 
under  the  skin. 

Through  the  altered  inclination  of  the  uterus  to  the  pelvis,  the 
OS  is  carried  too  far  up  and  the  presenting  part  is  prevented  from 
engaging. 

This  condition  is  due  to  distention  of  the  abdomen  by  previous 
pregnancies  or  tumors,  to  laparotomies,  or  umbilical  or  ventral  hernias. 
It  is  also  found  in  primiparte  in  consequence  of  a  narrow  pelvis  which 
prevents  the  normal  descent  of  the  presenting  part  into  the  pelvic 
cavity  during  the  latter  part  of  pregnancy. 

The  treatment  is  similar  to  that  mentioned  in  speaking  of  deficient 
abdominal  pressure  during  labor.  The  fundus  of  the  uterus  is  to  be 
raised  and  kept  in  place  with  a  tightly  adjusted  binder. 

Ventral  Fixation  and  Vaginal  Fixation  of  the  Uterus. — A  peculiar 
artificial  antedisplacement  of  the  pregnant  uterus  has  been  brought 
about  by  the  different  operations  by  which  the  anterior  surface  and 
the  fundus  of  the  uterus  are  fastened  to  the  abdominal  wall  or  the 
vagina.^  The  anterior  wall  being  fastened,  the  uterus  must  chiefly 
grow  by  expansion  of  the  posterior  wall,  and  the  os  is  carried  high  up. 
This  unnatural  position  of  the  uterus  gives  rise  during  the  progress 
of  pregnancy  to  much  discomfort,  such  as  a  dragging  pain  at  the 
seat  where  the  uterus  has  been  moored,  and  excessive  nausea  and 
vomiting,  and  it  leads  often  to  abortion.  During  labor  it  has  prevented 
engagement,  causing  inertia  and  rupture  of  the  uterus,  and  made 
delivery  impossible  by  the  natural  way,  so  that  in  several  cases  Csesarean 
section  became  necessary  to  bring  labor  to  an  end. 

Any  kind  of  fixation  of  the  uterus  itself  should,  therefore,  be  dep- 
recated, and  such  operations  be  substituted  which  shorten  or  attach 
the  round  ligaments,  and  among  these  again  the  preference  should  be 

1  Garrigues,  Diseases  of  "Women,  third  ed.,  p.  473. 


OBSTRUCTIONS   IN   THE    PARTURIENT    CANAL. 


421 


given  to  those  in  which  the  uterus  is  not  unnaturally  anteverted  or 
anteflexed. 

Latero VERSION. —  The  uterus,  in  most  cases,  is  tilted  more  or  less 
to  the  right  side  of  the  abdomen,  more  rarely  to  the  left.  This  rarely 
interferes  with  labor.  If  it  does,  the  malposition  is  easily  corrected 
by  placing  the  patient  on  the  opposite  side,  when  the  fundus  will  sink 
down  towards  the  couch,  and  the  os  move  in  the  opposite  direction. 

Sacculation. — If  the  presenting  part,  generally  the  head,  presses 
somewhat  unevenly  on  the  lower  uterine  segment,  this  will  be  dis- 
tended and  form  a  deep  pouch,  fitting  like  a  hood  over  the  foetus, 
while  the  os  remains  high  up  in  the  vault  of  the  vagina.  Most 
frequently  it  is  the  anterior  part  of  the  lower  uterine  segment  that 
undergoes  this  distention,  and  the  os  is,  therefore,  drawn  high  up 

Fig.  332. 


Anterior  sacculation  of  the  uteras.     (Tarnier  and  Budin,  1.  c.) 


behind  the  presenting  part  (Fig.  332)  in  the  neighborhood  of  the 
promontory. 

Much  more  rarely  it  is  the  posterior  part  of  the  lower  uterine 
segment  that  forms  the  sac,  while  the  os  is  found  above  the  sym- 
physis pubis  (Fig.  333).  A  similar  condition  has  been  found  with  a 
bicornute  uterus,  one  horn  developing  in  the  pelvic  cavity  and  the 
other  in  the  abdomen. 

We  have  seen  that  retroflexion,  as  a  rule,  corrects  itself  or  is  arti- 
ficially corrected.  It  happens,  however,  in  rare  cases  that  the  replace- 
ment is  not  total,  and  that  a  part  of  the  posterior  wall  of  the  uterus 


422 


ABNORMAL   LABOR. 


is  retained,  while  the  larger  part  of  it  and  the  whole  anterior  wall  are 
distended  by  the  growing  foetus.  In  this  kind  of  cases  the  labor-pains 
have  not  much  effect  on  the  os,  most  of  the  impetus  being  spent  in 
distending  that  part  of  the  lower  uterine  segment  which  forms  the' 
pouch. 

The  prognosis  is  better  in  anterior  sacculation  than  in  posterior. 
As  a  rule,  the  os  will  open  and  come  lower  down.  But  if  the  ab- 
normal distention  continues,  the  uterus  will  rupture. 

The  diagnosis  may  be  quite  difficult.  Sacculation  has  been  taken 
for  closure  of  the  os,  and  an  incision  has  been  made  in  the  uterus.     It 

Fig.  333. 


Posterior  sacculation  of  the  uterus.     (Taruier  and  Budin,  1.  c.) 

has  also  been  mistaken  for  a  fully  dilated  os,  the  distended  lower 
uterine  segment  being  so  thin  that  it  was  overlooked  and  the  forceps 
applied  outside  of  it.  The  pelvic  cavity  is  full,  although  there  is  no 
dilatation.  The  os  is  placed  at  the  bottom  of  a  deep  pouch  formed 
by  the  vagina.  If  it  is  not  within  reach  of  a  finger,  the  whole  hand 
must  be  introduced  during  anaesthesia.  If  the  os  is  in  front,  some- 
thing may  be  gained  by  placing  the  patient  in  the  knee-chest  position 
and  having  her  supported  by  assistants  (Fig.  260).  In  this  position 
the  patient  rests  on  her  knees,  the  upper  part  of  the  chest,  the  right 
side  of  the  face,  and  the  right  forearm.  The  thighs  are  kept  perpen- 
dicular, and  the  back  is  hollowed.  It  makes  the  fundus  of  the  gravid 
uterus  gravitate  strongly  forward  and  downward,  and  consequently 
brings  the  os  downward  and  backward. 


OBSTRUCTIONS    IN   THE    PARTURIENT    CANAL. 


423 


By  hooking  one  or  two  fingers  over  the  lower  border  of  the  os, 
it  is  gently  pulled  down  during  a  uterine  contraction,  which  may  be 
repeated  several  times,  until  the  os  is  brought  to  its  normal  position. 
It  has  been  found  necessary  to  make  numerous  small  incisions  in 
the  circumference  of  the  os.  In  another  case  the  foetus  was  turned 
and  extracted  by  the  feet,  and  in  one  even  Csesarean  section  was 
resorted  to. 

Partial  Prolapse. — The  whole  uterus  is  never  found  prolapsed  at 
full  term.  There  may  be  a  prolapse  of  the  lower  part  of  the  uterus 
and  the  cervix  become  hypertrophied  and  oedematous,  but  the  bulk 
of  the  uterus  is  in  or  above    the  pelvis.     Fig.  334  shows  such  a 

prolapse  with  a  protruding  foot. 
Fig.  334.  In  Fig.  335  is  represented  a  case 

of  head  presentation  with  prolapse 
and  hypertrophy  of  the  cervix. 

In    delivering    these    cases    the 
uterus  should  be  kept  back,  while 

Fig.  33-t 


Partial  prolapse  of  uterus  with  protruding 
foot.    (Wagner.) 


Prolapse  and  hypertrophy  oi  the  cervix  with 
head  presentation.     (Faivre.  i 


the  extraction  of  the  child  is  made  with  forceps  or  hand.  That  is 
most  readily  accomplished  by  covering  the  prolapsed  part  with  a  piece 
of  muslin  with  a  hole  corresponding  in  size  to  the  os. 

Uterine  Hernia. — The  whole  pregnant  uterus  at  term  has  been 
found  in  inguinal  and  more  rarely  in  femoral  hernia.  A  unicorn  or 
bicornute  uterus  is  predisposed  to  this  displacement.  The  best  treat- 
ment is  to  cut  down  on  the  uterus,  open  it  as  in  Caesarean  section, 
and  then  amputate  it. 

§  2.  Abnormalities  of  the  Cervix. — Conglutination  of  the  Ex- 
ternal Os. — It  has  been  contended  that  after  conception  the  os  may 


424 


ABXORMAL    LABOR. 


become  closed  by  agglutination  of  its  circumference.  Perhaps  this  is 
a  mistake.  By  careful  searching  a  small  opening  is  found  in  which 
hangs  a  drop  of  mucus,  which  is  surrounded  by  a  narrow  red  ring  of 
the  cervical  membrane  and  which  admits  a  uterine  sound.  If  this 
holds  good  in  all  cases,  there  would  then  not  be  an  agglutination,  but 
a  resistance  to  opening  of  the  os,  a  rigidity.  The  foetus  is  pushed  into 
the  cervical  canal,  which  becomes  enormously  distended  and  as  thin 
as  a  sheet  of  paper.  The  head  may  even  be  expelled  fi'om  the  geni- 
tals covered  by  the  cervix  (Fig. 
Fig.  336.  ^^6). 

If  there  is  a  real  agglutination, 
it  must  be  due  to  a  mild  degree 
of  inflammation.  If  there  is  none, 
the  resistance  has  been  attributed 
to  a  congenital  elongated  cervix 
or  to  density  of  the  cervical  tissue 
due  to  chronic  inflammation. 

It  may  be  impossible  to  feel 
the  OS.  The  patient  should  then 
be  put  in  Sims's  position  and  the 
vagina  exposed  with  Sims's  spec- 
ulum and  Garrigues's  retractor. 
When  the  os  is  found,  it  suffices 
often  to  press  on  it  with  a  finger, 
metal  catheter,  or  uterine  sound 
to  make  it  open  rapidly,  which 
would  favor  the  theory  of  a  real 
agglutination  having  taken  place. 
In  other  cases  the  cervix  retracts 
slowly,  and  has  to  be  pushed 
open  with  repeated  introduction 
of  the  sound  and  pressure  on  the  ring  or  by  pulling  it  apart  with  the 
fingers  as  in  Harris's  method  of  dilatation.  (See  Operations,  Fig.  422.) 
If  the  OS  is  really  closed  and  does  not  yield  to  pressure,  it  must  be 
opened  by  making  a  small  crucial  incision  over  it,  or  if  it  cannot  be 
found,  over  the  most  declive  place.  Before  deciding  on  these  some- 
what risky  procedures,  the  accoucheur  should  satisfy  himself  that  it  is 
not  a  case  of  sacculation  with  the  os  placed  high  up  in  front  or  behind. 
Closure  of  the  Cervical  Canal. — The  cervical  canal  may  become 
closed  after  conception  has  taken  place,  either  partially,  especially 
at  the  OS,  or  in  its  whole  length  by  formation  of  cicatricial  tissue. 
This  may  be  due  to  catarrh  or  ulceration  of  the  cervix,  but  is  more 
frequently  due  to  the  treatment  of  these  conditions  with  caustics  or 
to    operations   such  as  trachelorrhaphy,  amputation  of  cervix,  etc. 


o  e 


Conglutination  of  the  external  os.  (Jentzen. ) 
Head  covered  by  eerdx  expelled  from  genitals. 
PI,  placenta ;  C  C,  contraction  ring  ;  ves.,  bladder  ; 
oe,  external  os. 


OBSTRUCTIONS   IN   THE    PARTURIENT    CANAL.  495 

During  labor  the  foetus  can  descend  only  as  far  as  the  obstruction. 
If  uterine  contractions  do  not  suffice  to  overcome  it,  the  accoucheur 
must  remove  it,  if  possible,  by  means  of  a  sound,  but  if  he  does  not 
succeed  with  a  blunt  instrument,  he  must  have  recourse  to  sharp 
ones.  The  cervix  must  be  perforated  with  a  curved  trocar,  and 
perhaps,  besides  that,  incised  in  four  directions.  It  is  safer  to  make 
multiple  shallow  incisions  than  one  or  two  deep  ones. 

Stenosis  of  Cervix. — The  cervical  canal  may  be  narrow,  either 
from  congenital  malformation  or  inflammation  and  the  formation  of 
cicatrices.  In  these  cases  the  efforts  of  nature  may  be  assisted  by 
the  use  of  Barnes's  and  Champetier  de  Ribes's  dilators. 

Old  Cervical  Lacerations. — Cervical  lacerations  dating  from 
former  pregnancies  may  constitute  a  considerable  obstruction  to 
labor.^  The  cicatricial  plug  in  the  angle  of  the  tear  does  not  yield 
like  the  normal  muscular  tissue  of  the  cervix.  Especially  if  there  is  a 
bilateral  tear,  the  anterior  lip  becomes  oedematous  and  is  squeezed 
between  the  advancing  head  and  the  symphysis  pubis,  causing  a 
tedious  labor  and  great  suffering.  During  labor,  dilatation  should  be 
favored  by  hot  douches  and  Barnes's  dilators.  The  swollen  lip 
should  be  pushed  back  during  labor  pains,  and  when  sufficient 
dilatation  has  been  obtained,  the  forceps  should  be  applied.  A 
recurrence  should  be  avoided  by  performing  trachelorrhaphy  when 
full  involution  has  taken  place  and  before  the  beginning  of  a  new 
pregnancy,  say  at  the  end  of  the  second  month  after  childbirth.  The 
writer  has  repeatedly  seen  the  operation  followed  by  new  pregnancy 
and  labor,  without  any  difficulty  and  without  recurrence  of  the  tear. 

Rigidity. — Apart  from  conglutination  and  cicatricial  tissue  the 
cervix  and  os  may  fail  to  open  in  the  normal  way  under  the  impulse 
of  the  uterine  contractions.  This  is  called  rigidity  and  is  a  very 
common  occurrence.  In  primiparse  we  feel  the  edge  of  the  os  sharp 
and  tense  as  a  wire.  In  pluriparae  the  edge  often  remains  as  thick  as 
the  little  finger. 

In  other  words,  in  the  first  class  the  cervix  has  yielded  and  is 
being  distended  ;  in  the  second,  it  is  the  cervix  itself  which  does  not 
dilate  properly.  The  condition  is  most  frequently  met  with  in  old 
primiparae.  It  is  a  spastic  contraction  of  the  muscle-fibres  of  the 
cervix.  It  is  often  found  after  premature  rupture  of  the  membranes. 
The  soft  elastic  wedge  formed  by  the  liquor  amnii  being  lost,  the 
cervix  itself  is  pressed  between  the  presenting  part  and  the  pelvis, 
which  irritates  it.  A  nervous  temperament  and  fear  of  pain  can 
also  be  the  cause.  Uterine  contractions,  even  if  normal,  have  not 
the  normal  effect  on  the  cervix.     The  condition  is  so  common  with  a 

1  Garrigues,  "Laceration  of  the  Cervix  Uteri,"  Archives  of  Medicine,  Octo- 
ber, 1881. 


426  ABNORMAL    LABOR. 

mechanical  disproportion  that  this  always  is  my  first  thought  in  look- 
ing for  a  cause.  It  is  as  if  the  uterus  had  a  presentiment  of  the 
coming  struggle  and  had  not  the  courage  to  open  its  mouth. 

As  long  as  the  membranes  are  intact,  the  rigidity  is  of  little 
importance,  because  the  woman  and  the  foetus  are  protected  by  the 
liquor  amnii.  But  when  the  waters  have  broken,  it  is  fraught  with 
danger.  The  cervix  and  lower  uterine  segment  are  exposed  to  great 
pressure.  The  contused  parts  are  more  easily  infected,  the  patient 
becomes  feverish,  uterine  contractions  may  cease,  or,  if  they  continue, 
they  may  injure  the  cervix.  These  are  indeed  the  circumstances 
under  which  the  cervix  gives  way.  Most  often  the  tear  is  longitudinal. 
The  lateral  tears  may  extend  into  the  parametrium  and  cause  hemor- 
rhage or  inflammation  of  the  broad  ligaments.  In  rare  cases,  the 
laceration  being  transverse,  the  whole  end  of  the  cervix  is  torn  off 
as  a  ring. 

Treatment. — Chloral  hydrate,  gr.  xv  (1  gramme),  repeated  with 
twenty  minutes'  interval  till  two  or  three  doses  have  been  given,  is 
very  effective  in  removing  spasm.  If  the  cervix  is  thick,  sulphate  of 
atropine,  gr.  -^^  (1  milligramme),  may  be  injected  into  it  with  a  hypo- 
dermic syringe.  A  hypodermic  injection  of  morphine,  gr.  i  to  ^  (from 
1  centigramme  to  15  milligrammes),  is  also  useful.  A  rectal  supposi- 
tory containing  hydrochlorate  of  cocaine,  gr.  J  (3  centigrammes),  is 
also  recommended ;  if  necessary,  it  may  be  repeated  after  an  hour 
and  a  half.  Radix  ipecacuanhse,  gr.  v  every  twenty  minutes,  is  some- 
what disagreeable  on  account  of  the  nausea  it  produces,  but  it  softens 
the  cervix.  An  entire  lukewarm  bath  soothes  the  whole  nervous 
system  and  has  sometimes  a  good  effect  on  the  cervix.  Large,  tepid 
vaginal  douches  have  a  similar  effect.  If  these  milder  remedies  do 
not  suffice,  dilatation  should  be  furthered  by  means  of  Barnes's  elastic 
dilators  and  Champetier  de  Ribes's  unyielding  pear-shaped  bag,  which 
may  be  pulled  through  with  the  hand  or  an  attached  weight.  Harris's 
manual  dilatation  is  excellent.     (See  Operations.) 

There  are  also  different  expanding  metal  instruments. 

Personally,  I  have  found  the  above-mentioned  methods  sufficient 
for  all  purposes,  but  others  use  incisions.  They  may  easily  be  made 
by  inserting  a  blunt-pointed  bistoury  through  the  os,  after  having  cov- 
ered most  of  the  blade  with  a  strip  of  muslin.  During  a  pain  the 
edge  is  turned  against  the  circumference  of  the  os.  The  incisions 
may  also,  and  better,  be  made  with  a  pair  of  long-shanked,  curved, 
blunt  scissors  (Fig.  337). 

Small  incisions  of  this  kind,  not  extending  over  a  quarter  of  an 
inch  in  depth,  and  going  in  four  different  directions,  are  sometimes 
very  effective,  and  there  is  not  much  to  be  said  against  them,  although 
they  may  tear  somewhat.     The  hemorrhage  is,  as  a  rule,  controlled 


OBSTRUCTIONS    IN   THE    PARTURIENT   CANAL.  427 

by  hot  injections.  Exceptionally  tamponade  may  be  needed.  This 
is  an  old  method  and  different  from  Diihrsen's  method,  by  which  two 
lateral,  and  sometimes  an  additional,  anterior  and  posterior  incision 

Fig.  337. 


Cervix-scissors. 


are  carried  all  the  way  out  through  the  vaginal  portion  to  the  roof  of 
the  vagina. 

§  3.  Obstruction  in  the  Vag-ina. — Curiously  enough,  the  accou- 
cheur may  find  the  vagina  totally  closed  by  a  hymen  in  which  the 
closest  inspection  fails  to  discover  any  opening.  There  must  evidently 
have  been  one,  otherwise  impregnation  could  not  have  taken  place  ; 
but  the  opening  may  be  so  small  that  it  is  discovered  only  at  the  time 
of  menstruation,  and  such  a  fine  opening  may  become  obliterated  by 
an  inflammatory  adhesion,  thus  constituting  an  imperforate  hymen,  or 
atresia  hymenalis.  During  labor  the  bag  of  waters  presses  against 
the  closed  hymen,  distending  it  enormously  and  causing  great  pain. 
The  hymen  should  be  divided  by  a  crucial  incision.  There  will  hardly 
be  any  hemorrhage,  but  if  necessary  it  is  arrested  with  a  hot-water 
douche,  application  of  liquor  ferri  chloridi,  or  ligature. 

More  commonly  the  hymen  has  one  or  more  fine  openings,  but 
the  obstruction  in  regard  to  the  birth  of  the  child  is  practically  the 
same  as  when  the  membrane  is  imperforate,  and  the  treatment  is 
the  same.  A  hymen  with  several  fine  openings  is  called  a  hymen 
cribriformis.  In  other  cases  there  are  two  large  openings  separated 
by  a  septum,  Avhich  nearly  always  runs  in  an  anteroposterior  direc- 
tion. This  is  a  hymen  septus.  Such  a  band  is  generally  burst  by  the 
advancing  foetus.     If  not,  it  is  best  to  tie  it  at  both  ends  and  excise  it. 

In  the  vagina  proper  we  may  have  transverse  or  longitudinal, 
more  or  less  complete  septa. 

The  word  atresia  mesins  a  lack  of  lumen,  and  ought  to  be  used 
only  in  speaking  of  a  complete  closure,  whereas  stenosis  means  nar- 
rowness, and  may  properly  be  applied  to  any  condition  in  which  the 
vagina  has  not  its  proper  width. 

A  transverse  septum  with  one  or  more  small  openings  may  be 
found  in  any  part  of  the  vagina,  and  will  present  a  similar  obstacle 
to  that  of  an  imperforate  hymen. 

The  transverse  septum  may  have  considerable  thickness,  the  side 
walls  having  grown  together  over  a  more  or  less  extensive  area  in 


428  ABNORMAL   LABOR. 

consequence  of  sloughing  in  typhoid  fever,  diphtheritic  ulcers,  or 
cauterization.  Such  a  barrier  must  be  divided  with  incision  when 
distended  by  the  presenting  part,  and  even  Caesarean  section  may  be 
required. 

The  vagina  may  be  divided  into  two  halves,  each  corresponding 
to  one  of  the  Miillerian  ducts  from  which  it  is  developed.  Com- 
monly, but  not  always,  the  double  vagina  is  combined  with  a  double 
uterus. 

Instead  of  a  full-length  partition,  there  may  be  found  only  a  more 
or  less  narrow  band,  which  latter  oftener  causes  dystocia  than  the. 
former,  this  being  apt  to  burst  under  the  pressure  of  the  advancing 
foetus.  If  it  does  not,  it  must  be  severed,  preferably  with  thermo-  or 
galvanocautery.  A  band  is  simply  cut  with  scissors,  or  preferably 
tied  at  both  ends  and  removed. 

There  may  be  a  general  narrowness  of  the  vagina,  either  con- 
genital or  acquired  by  cicatrization.  Cicatrices  soften,  however,  re- 
markably during  pregnancy,  so  that  often  they  do  not  impede  labor. 
If  necessary,  room  should  be  procured  by  longitudinal  incisions, 
which  cause  less  injury  than  the  incalculable  tears  resulting  from 
over-distention.     Sometimes  the  forceps  is  used  to  advantage. 

Vaginism  ^  has  in  rare  cases  interfered  with  labor,  a  trouble  that 
is  easily  remedied  by  anaesthetizing  the  patient. 

§  4.  Diseases  of  the  Vulva. — Narrowness. — The  vulva  may  be 
congenitally  too  small  or  rigid  or  narrowed  by  cicatrices  due  to  burns, 
cauterization,  or  ulceration.  The  perineum  may  be  too  long,  either 
congenitally  or  in  consequence  of  operations  for  the  repair  of  lacera- 
tions sustained  in  former  labors.  The  lack  of  space  or  elasticity  is 
often  attributable  to  tender  or  advanced  age  in  primiparae. 

This  narrowness  or  rigidity  of  the  vulva  often  leads  to  laceration. 

Prophylaxis. — Much  may  be  done  in  order  to  prevent  or  limit 
these  injuries,  as  will  appear  later  on  when  we  come  to  treat  of  the 
laceration  of  the  perineum. 

If  no  other  means  seem  sufficient  to  prevent  laceration,  it  may 
sometimes  be  done  by  the  operation  called  episiotomy. 

If  the  indication  for  the  operation  is  too  small  dimensions  or 
rigidity,  an  incision  should  be  made  on  either  side  about  half  an 
inch  from  the  median  line,  behind  the  orifice  of  the  duct  of  Bartho- 
lin's gland,  and  carried  about  one-half  or  three-quarters  of  an  inch 
in  the  direction  of  the  tuberosity  of  the  ischium.  These  incisions  are 
best  made  with  a  pair  of  curved  scissors. 

If  incisions  are  to  be  made  on  account  of  cicatricial  tissue,  it 
is  best  to  use  a  bistoury  and  make  several  incisions  right  into  the 
constricting  part. 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  375. 


OBSTRUCTIOxNS   IX   THE    PARTURIENT   CANAL. 


429 


CEdema  of  the  vulva  may  be  found  combined  with  oedema  of  the 
lower  extremities  in  consequence  of  local  pressure  or  as  a  sequel 
of  albuminuria.  It  may  lead  to  deep  laceration  or  consecutive  gan- 
grene. Perhaps  simple  digital  compression  of  the  labia  majora  will 
relieve  the  swelling.  If  not,  the  labia  should  be  scarified  so  as  to 
give  an  exit  to  the  pent-up  serum. 

An  ABSCESS  OF  Bartholin's  gland  is  hardly  large  enough  to  obstruct 
labor,  but,  as  it  is  nearly  always  of  gonorrhoeal  origin  and  contains  a 
danger  of  infection,  it  should  be  laid  open  by  an  incision  extending 
over  its  whole  length,  washed  out,  swabbed  with  undiluted  carbolic 
acid  followed  by  alcohol,  and  packed  with  iodoform  gauze. 

Gangrene  of  the  vulva  is  very  rare,  but  might  offer  a  resistance 
to  normal  dilatation.  If  not  too  extensive,  it  should  be  cut  out  and 
the  woimd  treated  with  carbolic  acid,  alcohol,  and  styptic  cotton.  If 
extensive  it  might  induce  the  accoucheur  rather  to  perform  Csesarean 
section  than  to  run  the  risks  of  deep  tears  and  dangerous  infection. 

§  5.  Uterine  Tumors. — Myoma. — The  importance  of  myomatous 
tumors  as  a  cause  of  dystocia  varies  much  with  their  size  and  seat. 

Fig.  338. 


Pedicellate  subperitoneal  myoma  obstructing  labor.     (Stadicldt.) 


Small  myomas  in  the  upper  part  of  the  uterus  are  common  and  do  not 
in  any  way  interfere  with  labor.     Sometimes  they  are  taken  for  small 


430 


ABNORMAL    LABOR. 


parts  of  the  foetus,  but  the  latter  are  movable,  while  the  former  are 
stationary  in  the  uterine  wall.  The  subperitoneal  are  generally  less 
dangerous  than  the  interstitial  or  submucous  fibroids/  But  they  may 
be  so  large  that  they  interfere  with  uterine  contraction,  or,  if  they  are 
pediculate,  they  may  sink  down  into  the  pelvis  ahead  of  the  foetus 
(Fig.  338). 

The  intramural  and  submucous  may  prevent  contraction  after  the 
birth  of  the  child  and  become  the  cause  of  severe  post-partum  hem- 
orrhage. Pedunculated  submucous  myomas — so-called  fibrous  polypi 
— may  descend  ahead  of  the  foetus  and  prevent  its  progress,  but  some- 

FiG.  339. 


Retrocervical  fibromyoma  filling  the  pelvis.    Csesarean  section  at  term.     (Spiegelberg.) 


times  the  pedicle  tears  and  the  tumor  is  expelled.  Myomas  frequently 
give  rise  to  pelvic  or  transverse  presentation  or  to  placenta  praevia. 
In  the  puerperium  they  sometimes  become  gangrenous.  The  greatest 
danger  arises,  however,  when  the  tumor  has  its  seat  in  the  cervix, 
prevents  engagement,  or  even  fills  the  whole  pelvic  cavity  (Fig.  339). 
Such  a  case  has  some  resemblance  to  a  sacculated  uterus,  but  the 
vaginal  tumor  differs  from  a  fetal  head  or  breech  by  its  nodular 
structure  without  bones.    The  abdominal  part  of  a  tumor  has  a  similar 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  494. 


OBSTRUCTIOXS   IN   THE    PARTURIENT    CANAL.  481 

build  and  can  be  differentiated  by  its  hardness  from  the  elastic  uterus 
containing  the  liquor  amnii  and  the  foetus. 

During  pregnancy  myomas  grow ;  but  at  the  same  time  they 
become  softer,  a  point  well  to  be  remembered,  since  it  may  allow  the 
foetus  to  pass  or  enable  the  accoucheur  to  push  them  out  of  the 
way.  If  neglected,  they  may  lead  to  rupture  of  the  uterus  or  death 
by  exhaustion.     For  the  child  the  prognosis  is  also  very  doubtful. 

These  cases  must  be  watched  and  examined  most  carefully,  and 
mostly  demand  some  kind  of  assistance.  Still,  cases  that  filled  the 
accoucheur  with  anxiety  during  pregnancy  have  terminated  by  an 
undisturbed  normal  delivery.  The  best  way  is,  therefore,  generally 
speaking,  if  pregnancy  has  not  been  interrupted,  to  await  develop- 
ments at  the  time  of  labor. 

First  of  all  the  accoucheur  will  try  to  bring  an  obstructing  tumor 
from  the  pelvis  up  into  the  abdominal  cavity,  in  which  respect  the 
above-mentioned  softening  is  very  valuable.  The  reposition  may  be 
considerably  facilitated  by  placing  the  patient  in  Sims's  or  the  genu- 
pectoral  position.  It  may  be  necessary  to  introduce  four  fingers  or 
the  whole  hand  into  the  vagina.  If  it  is  an  internal  pedunculated 
tumor  that  is  in  the  way,  he  should  try  to  get  hold  of  it  with  a  fillet 
or  a  volsella  and  cut  the  pedicle.  An  excellent  instrument  for  this 
purpose  is  Thomas's  spoon-saw,  which  by  crushing  the  tissue  prevents 
hemorrhage.  If  this  instrument  is  not  available,  Bozeman's  strongly 
curved  scissors  may  be  used. 

If  the  tumor  is  situated  in  the  cervix  and  does  not  go  so  high  up 
that  its  upper  end  is  beyond  reach,  the  tumor  should  be  seized  at  its 
lowest  part  and  enucleated.^ 

If  a  fibroid  of  moderate  size,  situated  in  the  lower  uterine  segment, 
prevents  engagement,  version  may  be  resorted  to,  which  gives  better 
chance  than  the  forceps,  the  obstruction  being  so  high  up.  But  if  there 
is  a  partial  engagement,  the  forceps  may  be  tried.  If  there  is  not 
room  enough  for  the  undiminished  foetus  to  pass,  perforation  may  be 
needed. 

If  the  pelvis  is  filled  by  an  immovable  mass,  Caesarean  section  is 
indicated.  If  the  foetus  lies  in  front  of  the  womb  as  in  Fig.  339,  it  is 
safest  to  close  the  uterus,  and  leave  the  question  about  hysterectomy 
till  after  the  end  of  the  puerperium  ;  but  if  in  order  to  get  at  the  IVotus 
we  must  cut  or  enucleate  tumors,  it  will  be  necessary  to  remove  the 
uterus  by  supravaginal  amputation,  or,  if  the  cervix  is  implicated, 
perhaps  even  total  extirpation. 

After  the  birth  of  the  child  the  uterus  must  be  carefully  com- 
pressed, and  if  there  is  any  hemorrhage  injection  with  hot  Avater  or 
styptic  fluids  should  be  made  into  the  uterine  cavity. 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  505,  Figs.  290,  291,  p.  508. 


432 


ABNORMAL   LABOR. 


Carcinoma. — We  have  said  above  (p.  294)  that  if  a  woman  affected 
with  cancer  of  the  womb  is  seen  during  pregnancy,  the  uterus  sliould 
be  removed.  If  the  case  does  not  come  under  observation  before 
labor  has  begun  and  tlie  fffitus  is  living,  it  is  better  for  the  mother  if 
deep  incisions  are  made  in  the  cervix  and  the  child  dehvered  through 
the  vagina  by  means  of  version,  rarely  with  forceps.  If  cancerous 
masses  are  in  the  way,  they  must  be  scraped  off,  and,  as  there  is 
considerable  hemorrhage,  a  thermocautery  should  be  kept  ready. 

It  may  also  be  taken  under  consideration  to  perform  simple  Csesa- 
rean  section,  but.  if  the  cervix  is  somewhat  dilated  and  not  too  rigid 
and  the  foetus  not  too  large,  the  chances  for  the  mother  are  better  by 
vaginal  extraction. 

The  Csesarean  section  may  be  followed  by  total  extirpation,  if  the 
case  is  operable.  Finally,  both  delivery  and  extirpation  may  be  per- 
formed from  the  vagina, — so-called  vaginal  Ccesarean  section.  (See 
Operations.) 

If  the  foetus  is  dead  craniotomy  should  be  performed  and  the  foetus 
extracted. 

§  6.  Ovarian  Tumors. — We  have  seen  above  (p.  296)  that,  unlike 
uterine   myomas,    ovarian  tumors,  as   a   rule,    demand  interference 

Fig.  340. 


Head  arrested  at  brim  by  an  ovarian  cyst. 


during  pregnancy.     During  labor  they  offer  a  twofold  danger.     Either 
they  may,  on  account  of  their  large  size,  cause  such  an  obUquity  of  the 


OBSTRUCTIONS   IN   THE    PARTURIENT   CANAL.  433 

uterus  that  engagement  of  the  foetus  becomes  difficult  or  impossible ; 
or,  if  small,  they  may  enter  the  pelvic  cavity  ahead  of  the  fostus  (Fig. 
340).  This  is  most  frequently  the  case  with  the  slow-growing  der- 
moid cysts.  The  tumor  descends  generally  behind  the  vagina  in  the 
posterior  part  of  the  pelvis.  It  may  be  cystic  or  solid,  movable, 
impacted,  or  bound  down  by  adhesions. 

If  a  large  tumor  prevents  engagement  and  it  is  cystic,  the  best  way 
is  to  tap  it.  If  it  is  solid  or  semisolid  and  does  not  collapse,  it  must 
be  removed  by  ovariotomy.  If  an  ovarian  tumor  obstructs  the  vagina, 
we  may  try  to  replace  it  manually  like  a  pedicellate  myoma.  If  the 
replacement  prove  impossible,  the  accoucheur  should  tap  the  tumor 
through  the  posterior  vaginal  wall.  But  if  it  is  solid  and  cannot  be 
replaced,  ovariotomy  must  be  performed,  and  under  these  circum- 
stances the  abdominal  section  is  preferable  to  the  vaginal.^ 

§  7.  Other  Abdominal  Tumors. — Tumors  of  the  other  abdominal 
organs,  as  the  liver,  pancreas,  spleen,  kidneys,  mesentery,  omentum, 
the  broad  ligaments,  etc.,  have  in  rare  cases  caused  dystocia.  The 
difficulties  are  much  like  that  caused  by  ovarian  cysts,  and  similar 
principles  are  followed  in  the  treatment. 

The  one  that  has  been  observed  most  frequently  is  an  echinococcus, 
either  abdominal  or  pelvic.  Labor  may  end  spontaneously,  but,  as  a 
rule,  some  surgical  interference  is  needed,  especially  puncture,  appli- 
cation of  forceps,  manual  extraction,  or  even  the  Csesarean  section. 
These  cases  have  been  marked  by  a  great  maternal  mortality  (thirty 
per  cent.). 

HEMATOCELE  and  CYSTIC  SALPINGITIS  rarely  cause  obstruction,  but  if 
they  rupture,  especially  if  the  contents  are  purulent,  the  situation 
may  be  most  serious. 

§  8.  Vag-inal  and  Vulvar  Tumors. — True  vaginal  tumors — that 
is  to  say,  such  as  originate  in  the  vaginal  wall — are  rare,  and  rarely 
oppose  an  obstruction  to  labor.  Large  cysts  have  had  to  be  punc- 
tured to  give  passage  for  the  foetus.  Fibroids  or  carcinoma  may  have 
to  be  extirpated  or  diminished.  Vegetations  are  Lisually  soft,  but  may 
be  large  enough  to  form  an  obstruction,  which  should  be  removed 
with  a  thermo-  or  galvanocautery. 

In  another  sense  vaginal  tumors  are  quite  common — namely,  such 
as,  starting  from  other  organs,  either  hang  free  in  the  vagina — for 
instance,  a  polypus  of  the  cervix  uteri  (Fig.  341) — or  bulge  into  the 
lumen  of  the  vagina,  carrying  its  wall  before  them, — f.r/.,  uterine 
fibroids,  ovarian  tumors,  or  swellings  formed  by  the  bladder  or  the 
rectum. 

Hernia. — Herniae  do  not  form  a  real  obstruction,  but  there  is 
danger  of  their  impaction  and  compression,  which  may  lead  to  rup- 

'  Ganigues,  Diseases  of  Women,  third  ed.,  p.  641. 

28 


434 


ABNORMAL   LABOR. 


ture  or  gangrene  of  the  intestine.  Crural  hernia  is  least  exposed,  but 
inguinal  hernia  descending  into  the  labium  majus  and  forming  an 
anterior,  or  inguinolabkd,  hernia,  may  be  exposed  to  much  pressure. 
This  applies  still  more  to  vaginal  hernia,  or  vaginal  enterocele,  which 
follows  the  course  of  the  vagina.  It  most  frequently  starts  from 
Douglas's  pouch,  more  rarely  in  front  between  the  uterus  and  the 
bladder.  It  may  extend  into  the  labium  majus  from  behind,  forming 
a  posterior  labial  hernia,  or  vaginolabial  hernia. 

The  diagnosis  is  made  by  reducing  the  hernia  through  the  open- 
ing by  which  it  has  escaped,  and  this  is  also  the  mode  of  treatment. 
Taxis  should  be  exercised  in  the  intervals  between  contractions,  and 
once  replaced  the  hernia  should  be  kept  back  with  the  hand  until  the 

Fig.  341. 


Fibrous  polypus  of  cervix  occupying  the  vagina.     ( Toison. ) 


child  is  born.  In  vaginal  hernia  the  reposition  should  be  performed 
in  the  genupectoral  or  elevated  pelvis  position  and  the  intestine  kept 
in  until  the  presenting  part  has  descended  far  enough  to  close  the 
opening.  If  a  hernia  cannot  be  replaced  by  taxis,  labor  should  be 
terminated  as  soon  as  possible  by  version  or  forceps. 

The  bladder  may  be  the  cause  of  dystocia  in  different  ways. 
Simple  retention  of  urine  interferes  with  the  proper  contraction  of  the 
uterus,  and  a  full  bladder  may  become  the  cause  of  the  formation  of 
a  vesicovaginal  fistula,  when  the  base  of  the  bladder  is  compressed 
between  the  head  and  the  pelvis.  The  remedy  is,  of  course,  to  empty 
the  bladder,  but  this  is  not  always  easy.  A  common  female  catheter 
is  too  short  to  be  of  avail.     A  soft-rubber  catheter  may,  perhaps, 


OBSTRUCTIONS   IN    THE    PARTURIENT    CANAL.  435 

worm  its  way  in,  but  it  may  also  meet  a  resistance  which,  on  account 
of  its  very  flexibility,  it  is  unable  to  overcome.  Then  a  male  metal 
catheter,  especially  one  of  soft  metal,  whicli  can  be  bent,  is  the  instru- 
ment to  use.  Often  it  can  be  introduced  by  simultaneously  pushing 
back  the  presenting  part. 

Oystocele  forms  a  soft,  fluctuating  tumor  on  the  anterior  wall  of 
the  vagina.  The  urine  should  be  drawn  and  the  prolapse  kept  back 
until  the  presenting  part  has  passed. 

Calculus. — A  stone  in  the  bladder  has  in  a  number  of  cases  caused 
dystocia.  It  may  prevent  the  progress  of  the  foetus  or  it  may  injure 
the  bladder,  causing  a  vesicovaginal  fistula.  If  possible,  the  stone 
should  be  pushed  up  above  the  symphysis.  If  not,  an  incision  may 
be  made  in  the  median  line,  the  stone  extracted,  and  the  edges  united 
by  suture  after  delivery.  If  the  stone  is  not  too  large,  the  child  may, 
perhaps,  be  pulled  past  it  with  forceps  or  hand.  It  would  hardly  be 
right  under  such  circumstances  to  perform  craniotomy  on  the  living 
child ;  but  if  the  child  is  dead,  that  is  the  proper  thing  to  do.  If  the 
patient  is  seen  during  pregnancy,  a  small  stone  may  be  pulled  out 
through  the  dilated  urethra,  and  a  larger  crushed  by  litholapaxy,  and 
thus  the  danger  during  labor  be  averted. 

The  rectum  may  encroach  upon  the  vagina.  As  with  the  bladder, 
a  simple  accunuilation  of  fecal  matter,  forming  large,  hard  scybala, 
may  form  a  real  obstacle  to  labor.  The  case  is  aggravated  if  there  is 
a  prolapse  of  the  posterior  wall  of  the  vagina,  forming  a  pouch  into 
which  the  distended  rectum  descends.  The  treatment  consists,  of 
course,  in  the  removal  of  the  obstructing  feeces,  which  may  be  quite 
difficult.  The  best  way  of  obtaining  a  speedy  softening  of  the  scybala 
is  to  inject  half  an  ounce  of  glycerin,  break  the  mass  up  with  the 
index-finger,  and  scoop  it  out  with  a  teaspoon.  When  the  rectum  is 
free,  the  prolapsed  vaginal  wall  is  pushed  up  and  the  child  extracted 
with  forceps. 

Carcinoma  of  the  rectum  is  not  a  rare  disease,  but  it  does  not  often 
form  so  large  a  tumor  as  to  interfere  with  the  passage  of  the  foetus. 
In  exceptional  cases  extraction  has  been  made  with  the  forceps,  the 
head  has  been  perforated,  or  Caesarean  section  has  been  performed. 
In  deciding  on  the  last  two  operations,  the  degree  of  development  of 
the  cancer,  the  mother's  general  health,  and  the  chances  of  a  subse- 
quent operation  should  all  be  weighed.  It  would  not  be  right  to  sac- 
rifice a  living  child  in  the  interest  of  a  mother  doomed  shortly  to  die 
after  a  period  of  great  suffering. 


436  ABNORMAL   LABOR. 

CHAPTER   IX. 
DEFORMITIES    OF   THE    PELVIS. 

The  pelvis  may  be  too  small,  too  large,  or  irregular,  the  irregularity 
being  due  either  to  deviation  of  the  bones  or  to  tumors  springing 
from  them. 

The  too  small  pelvis  is  generally  called  a  narrow  or  contracted  pelvis. 
The  narrowness  may  be  found  at  the  upper  brim  alone,  or  at  least 
preponderatingly,  or  else  in  all  the  transverse  planes  which  we  may 
imagine  laid  through  the  pelvis.  It  may  be  found  in  only  one  diame- 
ter or  in  all.  The  brim  and  the  anteroposterior  diameter  are  by  far  the 
most  common  seat  of  the  narrowness. 

It  is  somewhat  difficult  to  give  a  precise  definition  of  what  con- 
stitutes a  narrow  pelvis.  We  cannot  go  by  the  character  of  the  labor 
alone,  because  here  three  factors  are  concerned, — the  size  of  the  pel- 
vis, the  size  of  the  child,  and  the  strength  of  the  expulsive  force.  We 
see  often  an  easy  labor  in  decidedly  contracted  pelves,  and  the  same 
woman  may  in  one  pregnancy  have  an  easy  confinement  and  in 
another  a  difficult  one. 

It  has,  then,  been  decided  to  go  by  the  measurements  of  the  pelvis, 
and  according  to  some  great  obstetricians  every  pelvis  the  true  conju- 
gate of  which  measures  3|  inches  (9  centimetres)  or  less  is  looked 
upon  as  narrow,  because  experience  has  shown  that  in  such  pelves 
generally  there  will  not  be  room  enough  for  the  passage  of  the  foetus, 
or  a  faulty  presentation  will  be  found.  Since  the  normal  distance  is 
4 J  inches  (11  centimetres),  it  is  evident  that  this  excludes  many  minor 
degrees  of  contraction,  which  occasionally  may  give  rise  to  dystocia, 
especially  if  at  the  same  time  there  is  some  contraction  of  the  trans- 
verse and  oblique  diameters,  or  if  there  is  some  weakness  in  the 
expellant  forces. 

The  narrowness  has  again  been  subdivided  into  three  degrees, 
placing  the  points  of  demarcation  between  the  different  degrees  at  3J 
inches  and  2  inches  (8  and  5  centimetres),  the  slightest  degree  of  con- 
traction being  the  field  for  the  forceps  or  version,  the  medium  degree 
leaving  the  choice  between  craniotomy  and  Csesarean  section,  and  the 
highest  degree  being  an  absolute  indication  for  the  Csesarean  opera- 
tion ;  but  these  rules  date  from  a  time  when  we  had  less  perfect  instru- 
ments for  the  extraction  of  the  foetus,  when  the  Csesarean  section  in  its 
old  shape  was  attended  by  such  a  mortality  that  it  nearly  amounted  to 
an  execution,  and  when  symphyseotomy  had  not  been  revived.  With 
the  improvement  in  management  and  technique,  capital  operations  are 
resorted  to  nowadays  under  very  different  circumstances  from  those 
prescribed  in  the  first  half  of  the  nineteenth  century.      Still,  these 


DEFORMITIES   OF   THE    PELVIS.  437 

figures  may  be  worth  retaining  in  tlie  memory,  since  they  may  be  of 
some  value  in  discussing  the  treatment  to  be  adopted  in  cases  of 
contracted  pelvis. 

Frequency. — There  obtains  the  greatest  variety  in  the  frequency 
with  which  contraction  of  the  pelvis  is  said  to  be  found.  Thus  Stad- 
feldt,  in  the  Royal  Lying-in  Hospital,  of  Copenhagen,  Denmark,  found 
only  3  per  cent,  in  a  thousand  patients  whose  pelves  were  accurately 
measured,  and  counting  as  narrow  all  pelves  the  diagonal  conjugate 
of  which  measured  4^  inches  (10.5  centimetres)  or  less,  instead  of  5 
inches  (13  centimetres).  In  German  lying-in  hospitals  the  percentage 
varied  between  7.9  per  cent,  and  24.3  per  cent. 

In  Austria  it  varied  between  2.15  and  7.8  per  cent. 

In  the  city  of  Paris  three  observers  found  respectively  16  per 
cent,,  8  per  cent.,  and  5  per  cent.,  which  shows  how  little  reliable 
their  statistics  must  be. 

In  America  we  find  a  similar  discrepancy  : 

Number  of  Percentage  of 

Obstetrician.                                                            Cases.  Narrow  Pelves. 

Whitridge  Williams,  Baltimore       .      .      .      1,000  13.1 

Crosse,  St.  Louis         800  7. 

Reynolds,  Boston 2,127  1.13 

Flint,  New  York 10,233  1.42 

But  by  closer  examination  the  difference  is  to  somQ  extent  made 
comprehensible. 

In  Baltimore  there  is  a  large  negro  population,  and  Dr.  Williams 
has  found  that  the  black  women  have  nearly  three  times  as  often  con- 
tracted pelves  as  the  white  women, — black  19.83  per  cent.,  white 
7.24  per  cent.  Furthermore,  Dr.  Williams  measures  the  diagonal  con- 
jugate without  reducing  it  to  the  true  conjugate  by  subtracting  more 
or  less  according  to  height  and  inclination  of  the  symphysis  pubis. 
So  did  Stadfeldt,  but  his  limit  was  placed  at  10.5  centimetres,  while 
Williams  looks  upon  every  pelvis  as  contracted  that  has  a  diagonal 
conjugate  of  11  centimetres  or  less,  and  in  the  generally  contracted  he 
places  the  limit  at  11.5  centimetres  or  less.  This  will,  of  course,  con- 
siderably increase  his  number  of  flat  pelves.  It  is  therefore  also  well 
worthy  of  attention  that  two-thirds  of  his  patients  had  spontaneous 
labors. 

On  the  other  hand,  Dr.  Reynolds  counted  as  contracted  only  those 
pelves  that  offered  a  marked  obstruction  to  the  passage  of  the  foetus 
and  required  operative  interference. 

Dr.  Flint  examined  the  records  of  the  Lying-in  Society  of  New 
York,  and  only  9  per  cent,  of  the  patients  were  Americans,  75  per 
cent,  were  Russians,  and  the  others  were  Poles  and  Bohemians.    His 


438  ABNORMAL   LABOR. 

statistics,  therefore,  concern  chiefly  the  Slavonic  races,  and  it  is  known 
from  the  statistics  of  Russian  lying-in  institutions  that  contracted 
pelves  are  rare  there.' 

I  have  so  much  less  reason  to  doubt  the  accuracy  of  the  measure- 
ments taken  in  Copenhagen,  as  my  personal  experience  in  New  York 
Maternity  during  a  period  of  eleven  years  as  visiting  obstetric  sur-. 
geon  has  taught  me  that  contraction  of  the  pelvis  is  rare  in  this 
locality.  I  have  no  statistics  to  offer,  and  we  took  as  routine  practice 
only  the  three  outer  measurements, — the  distance  between  the  ante- 
rior superior  spines  of  the  ihum,  the  crest  of  the  ilium,  and  the  exter- 
nal conjugate.  The  internal  conjugate  was  only  taken  when,  from  the 
external  measurements  or  the  course  of  labor,  we  had  reason  to 
believe  the  patients  had  a  narrow  pelvis.  On  the  other  hand,  accord- 
ing to  the  by-laws  of  the  hospital  every  single  case  in  which  a  pelvis 
caused  dystocia  came  under  the  personal  examination  and  treatment 
of  the  visiting  obstetric  surgeon.  Obstruction  to  labor  due  to  con- 
tracted pelvis  was  exceedingly  rare.  This  is  partly  accounted  for  by 
the  nationality  of  the  patients,  nearly  all  being  born  Americans  or 
Irish. 

With  the  increasing  immigration  from  Italy,  Bohemia,  Hungary, 
and  Russia,  I  do  not  doubt  that  bad  cases  of  pelvic  contraction  will 
become  more  common.  In  Europe  the  locality — that  is,  the  social 
status  of  the  patients  and  some  unknown  chmatic  influence — causes 
also  marked  .differences  in  the  frequency  with  which  narrow  pelves 
occur.  Thus  in  English  manufacturing  towns  rickets  are  common 
among  the  underfed  women  of  the  laboring  class.  On  the  borders  of 
the  beautiful  Rhine,  where  everything  bears  witness  to  the  wealth 
of  the  population,  and  in  the  fertile  Lombard  plain  in  Northern  Italy, 
osteomalacia  is  not  rare  and  furnishes  the  most  distorted  pelves. 

We  must  remember  that  difficult  cases  of  labor  are  found  mostly 
among  the  poor,  and  are  therefore  apt  to  gravitate  in  comparatively 
large  number  to  lying-in  asylums.  Among  the  well-to-do  in  private 
practice  the  narrow  pelvis  is  much  rarer  than  in  public  institutions. 

Etiology. — The  cause  of  pelvic  contraction  is  nearly  always  devel- 
opmental ;  much  more  rarely  the  narrowness  is  acquired  later  in  life. 
We  have  seen  (p.  144)  how  the  fetal  pelvis  is  changed  into  that  of  the 
adult.  Three  chief  factors  are  at  work, — the  weight  of  the  upper 
part  of  the  body,  the  resistance  offered  by  the  strong  pelvic  ligaments, 
and  the  pressure  of  the  femora  against  the  acetabulum.  When  all 
these  forces  are  in  harmony,  the  result  is  the  change  from  the  form  of 
the  pelvis  of  the  child  to  the  normal  shape  of  the  pelvis  of  the  adult ; 
but  if  the  harmony  is  disturbed  by  preponderance  of  one  over  the 
others,  the  configuration  of  the  pelvis  is  vitiated. 

1  Whitridge  Williams,  Obstetrics,  May,  1899,  vol.  i.,  No.  5,  pp.  242-253. 


DEFORMITIES    OF   THE   PELVIS.  439 

There  may  be  an  hereditary  predisposition  to  narrowness  of  the 
pelvis.  -Thus  it  is  not  rare  to  find  the  same  form  of  pelvis  in  mother 
and  daughter.  Among  congenital  defects  that  may  cause  contraction 
may  be  named  rickets,  dislocation  of  one  or  both  femora,  split  pelvis, 
club-foot,  flat-foot,  etc.  During  childhood  rickets  is  the  chief  disease 
that  leads  to  a  narrow  pelvis.  More  rarely  coxitis  causes  unequal 
pressure  from  the  two  lower  limbs,  or  tuberculosis  of  the  vertebral 
column  causes  a  collapse  obstructing  the  pelvis,  or  deviations  of  the 
vertebrae  cause  a  change  in  the  direction  of  pressure  from  above. 

In  adult  life  the  form  of  the  pelvis  may  be  changed  through  injury, 
osteomalacia,  or  the  formation  of  tumors. 

Diagnosis. — The  diagnosis  of  a  contracted  pelvis  in  the  higher 
degrees  or  of  unusual  forms  is  an  easy  matter,  but  the  minor  degrees, 
which  still  may  cause  considerable  dystocia,  are  not  easily  recognized, 
and  the  accoucheur  should  therefore  avail  himself  of  every  means 
of  ascertaining  as  much  and  as  early  information  as  possible  about 
his  patient,  for  here  the  old  saying  holds  good,  "  forewarned  is  fore- 
armed." The  knowledge  of  the  presence  of  a  narrow  pelvis  in  a 
patient  often  enables  him  to  avert  evil,  or  to  prepare  himself  to  meet 
the  difficulties  that  may  be  expected  during  labor. 

The  history  of  the  case  is  not  without  value.  If  the  patient  has 
borne  children  before,  she  may  be  able  to  tell  whether  the  labor 
lasted  unusually  long,  whether  instruments  were  used,  whether  the 
children  were  born  alive  or  some  destructive  operation  was  per- 
formed, and  whether  they  were  born  by  the  natural  passage.  Per- 
haps the  patient  was  told  at  the  time  that  she  had  a  narrow  pelvis. 
She  may  know  if  there  were  any  wounds  on  the  heads  of  the  chil- 
dren when  they  were  born,  and,  if  they  are  alive,  they  may  still  have 
depressions  in  places  on  the  skull.  We  inquire  about  the  woman's 
general  health,  especially  in  childhood,  whether  or  not  she  began  to 
walk  at  the  usual  age,  and  whether  she  has  had  any  affection  of  the 
bones  or  joints.  Next,  the  accoucheur  should  ask  if  she  knows  what 
kind  of  labors  her  mother  had. 

The  appearance  of  the  patient  may  give  some  information.  If 
she  is  of  unusually  small  size,  that  will  make  it  likely  that  she  has  a 
small  pelvis.  If  her  hips  do  not  bulge  out  as  in  the  normal  woman, 
but  approximate  the  male  type,  and  if  she  is  too  flat  in  the  sacral 
region,  we  may  expect  to  find  a  narrow  pelvis.  Deviations  of  the 
spinal  column  and  a  halting  gait  are  of  great  importance.  A  pendu- 
lous abdomen  in  a  primipara  is  also  suspicious. 

While  the  history  and  the  general  appearance  thus  may  make  us 
surmise  that  we  may  have  to  deal  with  a  contracted  pelvis,  the  exact 
knowledge  of  the  presence  of  such  deformity,  its  type,  and  degree, 
can  be  ascertained  only  by  exact  external  and  internal  physical  exam- 


440  ABNORMAL   LABOR. 

illation.  We  have  already  described  the  common  way  of  examining 
the  pelvis  with  the  pelvimeter  (pp.  115-117)  and  the  hand. 

The  external  pelvimetry  is  of  minor  importance.  Of  the  three 
measurements  it  furnishes,  that  of  Beaudelocque's  diameter  is  the 
most  valuable.  But  in  order  to  ascertain  by  its  means  the  size  of 
the  internal  true  conjugate,  we  ought  to  be  able  to  subtract  the 
thickness  of  the  bones,  fat,  and  skin  that  make  up  the  difference  in 
length  between  the  internal  and  the  external  conjugate,  and  that  is 
impossible  to  measure  and  hard  even  to  approximate.  It  has  therefore 
been  decided  to  subtract  the  average  thickness,  which  is  3^  inches, 
in  order  to  calculate  the  inner  diagonal.  The  normal  measure  being 
eight  inches,  that  leaves  four  and  one-half  for  the  true  conjugate  in 
the  normal  pelvis,  which  is  rather  too  much,  since  the  average  true 
conjugate  is  only  four  and  one-quarter  inches,  and  the  available  con- 
jugate is  only  four  inches.  We,  therefore,  come  nearer  the  truth  by 
dividing  the  external  conjugate  into  two  halves,  and  counting  on  one- 
half  its  length  as  what  w^e  may  expect  the  available  conjugate  to  be  ; 
but  the  calculation  is  too  unreliable  for  practical  use,  and  has  given 
way  to  that  based  on  the  length  of  the  diagonal  conjugate  found  by 
internal  pelvimetry. 

The  relation  between  the  external  transverse  measurements  of  the 
false  pelvis — the  distance  between  the  anterior  superior  spines  and 
the  crests  of  the  ilium — and  the  length  of  the  transverse  diameter  of 
the  brim  of  the  true  pelvis  is  still  less  constant.  Still,  with  all  their 
imperfections  the  measurements  of  the  false  pelvis  furnish  us  with 
information  not  to  be  despised.  If  all  the  measurements  are  below 
-the  normal  standard,  there  is  a  strong  presumption  that  the  true 
pelvis  is  also  generally  contracted.  Of  still  greater  value  is  the  pro- 
portion between  the  length  of  the  distance  between  the  anterior 
superior  spines  of  the  ilium  and  that  between  the  crests  of  the  ilium. 
If  the  former  is  as  long  as  or  longer  than  the  latter,  the  pelvis  is 
rickety.  If  the  distance  from  one  posterior  superior  spine  to  the 
ihopectineal  eminence  of  the  other  side  is  considerably  longer  than 
the  corresponding  distance  on  the  other  side,  it  proves  that  the  pelvis 
is  obliquely  contracted. 

Of  much  greater  importance  is  the  internal  examination  of  the 
pelvis,  when  the  fingers  come  in  direct  contact  with  the  walls  of  the 
canal  we  want  to  examine.  We  have  described  above  (p.  115)  how 
the  diagonal  conjugate  is  measured,  and  stated  that  its  average  length 
is  five  inches.  But  what  we  really  are  interested  in  is  the  length  of 
the  true  conjugate,  or  rather  of  the  available  conjugate,  and  the  ques- 
tion is  how  we  can  deduct  one  from  the  other.  A  glance  at  Figs. 
342-344  win  show  that  the  available  or  minimum  diameter  forms  a 
triangle  with  the  symphysis  pubis  and  the  diagonal  conjugate,  and  that 


DEFORMITIES   OF   THE   PELVIS. 


441 


the  proportion  between  the  length  of  the  available  and  the  diagonal  de- 
pends on  four  factors  :  first,  the  inclination  of  the  symphysis  ;  second, 


Fig.  342. 


Rickety  pelvis,  medium  inclination  of  symphy- 
sis, angle  at  »;i  95°,  medium  height  of  promontory. 
(Tarnier  and  Budin,  1.  c.)  Pm,  minimum  conju- 
gate ;  PSp,  diagonal  conjugate;  PmSp,  promon- 
torio-pubic  triangle. 


Rickety  pelvis.  Promontory  high  up,  sym- 
physis little  inclined.  (Tarnier  and  Budin, 
1.  c. )    Letters  as  in  Fig.  342. 


the  height  of  the  symphysis  ;  third,  the  thickness  of  the  symphysis  ; 
and  fourth,  the  height  of  the  promontory.     The  greater  the  inclination 
of  the  symphysis  is,  the  less  differ- 
ence there  will  be  between   the  ^^' 
two  long  sides  of  the  triangle.    The 
higher  and  thicker  the  symphysis 
is,  the  greater  the  difference  will 
be.     The  higher  the  promontory 
is  situated  above  the  symphysis, 
the  less  the  difference  will  be.    In 
examining  a  pelvis  the  accoucheur 
may  weigh  all  these  points  in  his 
mind,  and  they   will  have    som'^ 
influence  in  deciding  how  mucn 
he  should  subtract  from  the  length 
of  the  diagonal  conjugate  in  de- 
termining the  length  of  the  avail- 
able diameter.    But  by  examining 
a  large  number  of  dry  pelves  it  has  been  found  that  the  subtraction 
of  five-eighths  of  an  inch  (fifteen  milHmetres)  gives  the  least  error. 


Rickety  pelvis.    Promontory  very  low,  symphy- 
sis strongly  inclined.    Letters  as  in  Fig.  342. 


442 


ABNORMAL   LABOR. 


Fig.  345. 


Many  instruments  have  been  invented  in  the  hope  of  determining 
more  exactly  the  internal  measurements  of  the  pelvis,  but  they  are 
difficult  to  use,  unreliable,  or  painful.  Practical  obstetricians  have 
therefore  very  generally  come  to  the  conclusion  that  manual  internal 
pelvimetry  is  to  be  preferred. 

If  sufficient  information  cannot  be  obtained  by  usmg  one  or  two 
fingers,  it  may  be  necessary  to  introduce  half  the  hand  (that  is,  the 
four  fingers)  or  the  whole  hand.  Since  this  is  very  painful,  the  patient 
must  be  anaesthetized. 

The  transverse  diameter  is  of  less  importance  than  the  antero- 
posterior, but  if  the  latter  is  shortened  a  concomitant  reduction  of  the 
transverse  diameter  increases  the  difficulties  materially.  By  intro- 
ducing the  hand,  spreading  the  fingers,  and  moving  them  from  side 
to  side,  some  idea  may  be  formed  of  its  length. 

In  regard  to  the  outlet,  the  transverse  measurement  may  be  taken 
more  accurately  by  applying  the  first  and  second  fingers  against  the 
inside  of  the  tuberosities  of  the  ischia  and  inserting  the  fingers  of  the 
other  hand  as  a  wedge  to  keep  them  in  place  while  they  are  being 
withdrawn  and  the  distance  from  one  to  the  other,  outer  measure,  is 
taken.     The  anteroposterior  diameter  of  the  outlet  is  easy  to  take  by 

placing  the  second  finger  on  the  articu- 
lation between  the  movable  coccyx  and 
the  sacrum  and  marking  the  distance  to 
the  subpubic  arch  as  in  measuring  the 
diagonal  conjugate  of  the  brim. 

It  may  be  necessary  to  compare  the 
two  sides  of  the  brim,  in  order  to  find 
out  if  there  is  any  asymmetry  in  their 
shape  and  how  much  space  there  is. 
For  this  purpose  the  two  hands  should 
be  used  alternately,  the  homonymous 
hand  being  used  for  each  side — the  right 
hand  for  the  right  side  of  the  pelvis,  the 
left  hand  for  the  left  side.  Otherwise 
that  side  towards  which  the  pulp  of  the 
fingers  is  naturally  turned  will  appear 
larger. 

In  measuring  the  diagonal  conjugate 
the  accoucheur  may  be  deceived  by  a 
so-called  double  promontory  (Fig.  345). 
The  line  of  union  between  the  first  and  the  second  sacral  vertebra,  or 
that  between  the  fourth  and  the  fifth  lumbar  vertebra,  may  be  so 
prominent  that  the  distance  from  it  to  the  symphysis  has  the  same 
length  as  or  is  even  shorter  than  that  between  the  true  promontory 


Double  promontory.  (Fiirst.)  P, 
promontory;  P",  false  promontory,  be- 
tween first  and  second  sacral  vertebrse  ; 
P  C.V.,  true  conjugate  ;  P  C.d.,  diagonal 
conjugate;  P"  C.v.  and  P'C.d.,  the  cor- 
responding lines  from  the  false  prom- 
ontory, are  shorter,  and  are  those  to  be 
considered  as  indicating  the  degree  of 
narrowness. 


DEFORMITIES    OF  THE    PELVIS.  443 

and  the  symphysis.  The  adventitious  prominence  forms,  indeed,  a 
false  promontory.  The  true  promontory  can,  however,  be  recognized 
in  such  cases  by  carrying  the  examining  fingers  out  to  the  side  and 
satisfying  one's  self  that  the  alae  of  the  sacrum  are  situated  on  a 
level  slightly  below  it. 

In  a  primipara  the  lack  of  engagement  of  the  presenting  part  must 
awaken  the  suspicion  of  a  narrow  pelvis,  while  in  pluriparas  the  foetus, 
as  a  rule,  does  not  engage  in  the  pelvic  cavity  before  labor  begins. 

Another  source  of  information  as  to  the  narrowness  of  the  pelvis 
is  found  in  the  presentation  and  attitude  of  the  foetus  during  labor. 
Abnormal  presentations,  such  as  cross,  pelvic,  or  face  presentations, 
and  the  prolapse  of  the  cord  or  of  extremities  at  the  side  of  the  head, 
are  much  more  common  in  narrow  pelves  than  in  normal,  especially 
in  primiparae.  Retrofiexion  of  the  gravid  uterus  is  also  more  apt  to 
be  found  in  a  pelvis  where  an  abnormally  protruding  promontory  holds 
the  enlarged  uterus  imprisoned  in  the  cavity  than  in  a  normal  pelvis. 
Premature  rupture  of  the  membranes  and  slow  dilatation  of  the  os  are 
also  very  common  with  narrow  pelves. 

The  mechanism  of  labor  may  be  characteristic.  Thus,  in  a  gener- 
ally contracted  pelvis  the  small  fontanelle  sinks  unusually  deep  down, 
while  in  a  flat  pelvis,  on  the  contrary,  the  large  fontanelle  is  apt  to 
sink  down  to  a  lower  level  than  the  small. 

The  shape  of  the  head,  the  presence  on  it  of  wounds  due  to  press- 
ure against  the  pelvic  bones,  or  indentations  of  the  cranial  bones,  may 
not  only  bear  witness  to  the  existence  of  a  narrow  pelvis,  but  allow 
us  indirectly  to  take  an  exact  measure  of  the  narrowest  passage  by 
measuring  the  distance  between  two  opposed  marks.  This  last  class 
of  information  is  only  obtained  after  termination  of  the  labor,  but  it 
is  of  great  value  for  later  pregnancies  of  the  same  patient. 

To  resume,  the  diagnosis  of  a  narrow  pelvis  is  based  upon  the 
history  of  the  case,  the  appearance  of  the  woman,  the  physical  ex- 
amination of  her  pelvis,  peculiarities  in  the  mechanism  of  labor,  the 
configuration  of  the  child's  head,  and  marks  on  it. 

Classification. — There  is  a  great  variety  of  deformed  pelves,  which 
are  classified  in  many  different  ways  by  authors  on  obstetrics.  This 
being  an  entirely  practical  work,  I  think  it  is  in  the  interest  of  the 
reader  first  of  all  to  distinguish  common  forms,  which  everybody  may 
meet  with  who  is  engaged  in  obstetric  practice,  and  then  the  rarer 
forms,  which  he  perhaps  never  will  see,  which  are  found  as  curiosities 
in  museums,  or  which  are  almost  limited  to  some  particular  locality. 
Next,  I  shall,  as  has  been  my  aim  throughout  the  work,  go  from  the 
simple  and  easy  to  the  more  comphcated  and  difficult.  I  shall  be 
guided  chiefly  by  palpable  deviations  of  form,  and  secondarily  by 
etiological  considerations. 


444  ABNORMAL   LABOR. 

Following  these  principles,  deformed  pelves  may  be  classified  in 
the  following  way : 

A.    Common  Deformities. 
1.   Generally  equally  contracted  pelvis. 

Subdivisions  : 

1.  Well-shaped,  generally  contracted. 

2.  Male  type. 

3.  Infantile. 

4.  Rhachitic,  generally  contracted. 

IL   Flat  pelvis. 

Subdivisions  : 

1.  Simple  flat  pelvis. 

2.  Rhachitic  flat  pelvis. 

3.  Generally  contracted  flat  pelvis. 

4.  Pelvis  flattened  by  dislocation  of  both  femora. 

B.   Rarer  Deformities. 

\.   Asymmetric  pelvis. 

Subdivisions  : 

1.  Scoliotic  asymmetric  pelvis. 

2.  Obliquely  contracted  pelvis  {Naegele pelvis). 

3.  Coxalgic  pelvis. 

IL  Transversely  contracted  pelvis. 

Subdivisions  : 

1.  Ankylosed,  transversely  contracted  pelvis  {Robert  pelvis). 

2.  Kyphotic  pelvis. 

3.  Funnel-shaped  pelvis. 

III.  Incurved  pelvis. 

Subdivisions  : 

1.  Osteomalacic  pelvis. 

2.  Pseudo-osteomalacic  rhachitic  pelvis. 

IV.  Spondylolisthetic  pelvis. 

V.   Pelvis  contracted  by  tumors  springing  from  the  pelvic  bones. 

VI.   Spht  pelvis. 

Subdivisions  : 

1.  Split  at  the  site  of  the  symphysis  pubis. 

2.  Split  at  the  site  of  the  sacrum. 

A.    Common  Deformities. 

§  1.  Generally  Equally  Contracted  Pelvis,  or  Justo  Minor 
Pelvis. — I  place  the  generally  equally  contracted  pelvis  at  the  head 
of  the  list  partly  because  it  is  the  form  that  comes  nearest  to  the 
normal  forms  of  pelvis  with  which  we  are  familiar  in  the  infant  and 


DEFORMITIES    OF    THE    PELVIS. 


445 


in  the  adult  woman,  and  partly  because  it  is  the  form  most  commonly 
met  with  in  New  York  and,  it  would  seem,  other  Eastern  cities. 

When  we  call  it  the  generally  equally  contracted  pelvis  this 
expression  must  not  be  taken  too  literally.  Sometimes  the  general 
contraction  is  only,  or  at  least  chiefly,  found  at  the  brim,  and  the 
anteroposterior  diameter  may  be  a  little  more  contracted  than  the 
other  diameters.  On  account  of  the  diminution  in  the  diameters  of 
the  pelvis,  even  if  it  is  not  very  great,  taking  place  in  all  directions,  this 
form  may  oppose  considerable  resistance  to  the  passage  of  the  foetus. 

An  equally  contracted  pelvis  may  be  entirely  normal,  except  that 
it  is  too  small.  In  most  cases  the  bones  are  slender  and  light.  Such 
well-shaped  but  too  small  pelves  may  be  found  in  women  who  other- 
wise are  well  proportioned.  It  may  be  found  also  in  women  of  small 
stature. 

Fig.  346. 


Generally  contracted  pelvis,  mali'  typo,  ^oon  from  above.    (Author's  case.) 


The  smallness  of  this  pelvis  culminates  in  dwarfs — the  dwarf 
pelvis,  or  pelvis  nana.  The  dwarf  pelvis  has  the  shape  of  that  of  a 
girl  at  puberty,  and  the  ossification  is  deficient.  It  is  characteristic 
for  the  higher  degrees  of  generally  equally  contracted  pelves  that  the 
whole  linea  terminalis  may  be  felt  with  one  finger. 

In  other  cases  the  pelvis  approaches  the  male  type  of  pelvis  (Figs. 
346,  347).  The  brim  is  more  round,  the  ilia  rise  more  perpendicu- 
larly, the  pubic  arch  is  narrow,  and  the  bones  ar^  thick  and  heavy. 


446 


ABNORMAL   LABOR. 


In  other  cases,  again,  the  pelvis  has  preserved  features  of  the 
infantile  pelvis  (Fig.  348).  The  innominate  bone  is  more  perpendicu- 
lar and  may  be  divided  in  its  three  component  parts.  The  pelvic  brim 
is  more  round,  or  even  forms  an  oval  lying  in  the  anteroposterior  di- 
rection. The  sacrum  is  narrow  and  more  straight.  The  symphysis 
is  less  inclined  than  normal. 

A  particular  variety  of  infantile  pelvis  is  found  in  women  who 
have   spent   their  whole    childhood    in    a   recumbent   position — the 


Fig.  347. 


Generally  contracted  pelvis,  male  type,  front  view.     (Same  specimen  as  in  Fig.  346.) 

pelvis  of  reclination.  The  preponderance  of  the  conjugate  over  the 
transverse  diameter  is  well  marked,  the  innominate  bones  are  nearly 
perpendicular,  and  the  pubic  arch  is  wide  (Fig.  349). 

An  equally  contracted  pelvis  of  the  infantile  type  is  found  in  idiots 
and  other  weak-minded  women,  combined  with  defective  develop- 
ment of  the  external  and  internal  genitals. 

The  equally  contracted  pelvis  may  be  of  rhacJiitic  origin,  which 
shows  in  the  characteristic  proportion  between  the  length  of  the 
distance  between  the  anterior  superior  spines  of  the  ilia  and  that 
between  the  crests.     This  is  a  rare  variety. 

The  generally  equally  contracted  pelvis  being  so  near  the  normal, 
the  mechanism  of  labor  is  also  much  the  same ;  but  a  characteristic 
sign  is  the  lower  position  of  the  posterior  fontanelle.     Room  being 


DEFORMITIES    OF   THE    PELVIS. 


447 


scant,  the  normal  flexion  of  the  neck  is  exaggerated  so  as  to  allow 
the  head  to  descend  with  its  smallest  circumference, — the  suboccipito- 
bregmatic, — which  measures  only  eleven  inches  (twenty-eight  centi- 
metres). Thus  the  posterior  fontanelle  is  brought  down  and  nearer 
the  centre  of  the  pelvis  than  in  pelves  of  normal  shape.  Labor 
progresses  slowly  and  uterine  contractions  are  liable  to  become  weak. 
The  shape  of  the  head  after  delivery  through  a  generally  contracted 

pelvis  is  also  characteristic.  It 
^^^-  •^^^-  is  compressed  in  its  suboccipito- 

bregmatic     circumference    and 

Fig.  349. 


Infantile  type  of  pelvis. 


Pelvis  of  reclination.    (Biittner.) 


bulges  out  in  the  direction  of  the  posterior  fontanelle.  In  other 
words,  it  is  pointed,  with  an  increase  of  the  occipitomental  diameter. 

Besides  this  elongation  of  the  head  there  is  sometimes  found  a 
lateral  flexion  or  torsion  produced  by  the  occiput  tending  to  get  under 
the  pubic  arch  while  the  anterior  temple  is  still  retained  at  the  brim 
and  pressed  against  the  anterior  wall  of  the  pelvis. 

The  equally  contracted  pelvis  is  not  so  likely  to  produce  pressure 
marks  on  the  head  of  the  foetus  as  other  forms  of  contracted  pelvis. 

Diagnosis. — The  size  of  the  pelvis  and  the  low  place  of  the  pos- 
terior fontanelle  make  the  diagnosis  clear. 

Prognosis. — No  child  can  pass  through  a  dwarf  pelvis  ;  the  only 
means  of  relief  is  to  be  found  in  the  Caesarean  section.  In  medium 
degrees  of  contraction  the  child  may  be  born  by  nature's  sole  effort  or 
by  the  intervention  of  art.  There  is  usually  such  a  difficulty  in  pulling 
the  aftercoming  head  through  that  the  child  is  likely  to  die  if  version 
is  performed.  The  resistance  not  being  confined  to  one  ring,  but 
going  through  the  whole  passage,  and  even  increasing  as  the  head  is 
pulled  deeper  into  the  cavity,  forceps  operations  are  difficult,  and  often 
lead  to  the  death  of  the  foetus,  when  the  forceps  has  to  be  abandoned 
for  the  perforator.    The  mother  may  die  from  exhaustion  or  infection. 


448  ABNORMAL   LABOR. 

Treatment. — Impressed  by  the  great  infantile  mortality  and  the 
frequent  loss  of  the  mother  Avhen  delivery  was  sought  to  be  effected 
per  vias  naturales,  years  ago  the  author  entered  on  the  record-book 
of  Maternity  Hospital  his  opinion  that  Csesarean  section  gave  both 
mother  and  foetus  much  better  chances.  That  was  before  the  revival 
of  symphyseotomy.  Now  I  take  this  to  be  the  operation  indicated 
as  soon  as  moderate  traction  with  the  forceps  proves  ineffective. 

§  2.  Flat  Pelvis. — A  flat  pelvis  is  one  whose  true  conjugate  is 
shorter  than  normal.  The  pelvis  has  consequently  an  abnormal  shape. 
The  transverse  diameter  of  the  brim  may  be  of  normal  length  or  even 
longer.  The  flatness  may  be  limited  to  the  superior  strait  or  may 
extend  through  the  whole  pelvis. 

Flat  pelves  may  be  divided  into  three  groups, — the   simple  flat 

pelvis,  the  rhachitic  flat-pelvis,  and  the  generally  contracted  flatjDelvis. 

1.  Simple  Flat  Pelvis. — The  simple  flat  pelvis  (Fig.  350)  is  a  flat 

pelvis  in  an  individual  who  has  no  history  of  having  been  affected  with 

rhachitis  in  childhood  and  who  does 
Fig.  350.  not   show   any   signs  of  that   disease 

either  in  the  pelvis  or  in  any  other 
part  of  the  skeleton. 

In  this  variety  the  bones  of  the 
pelvis  are  of  normal  thickness,  but 
small,  esiDecially  the  sacrum.  The  nar- 
rowness frequently  extends  through- 
out the  pelvis,  even  if  it  is  most  marked 
at  the  brim.  The  outlet  is  not  en- 
larged. The  transverse  diameters  are 
Simple  flat  pelvis,  (oishausen-veit. ,  normal  or  at  Icast  uot  materially  elon- 
gated. This  is  the  most  common  form 
of  all  flat  pelves.  The  narrowness  is  moderate  and  hardly  ever  goes 
below  a  true  conjugate  of  3 J  inches  (8  centimetres).  But  on  account 
of  the  extension  of  the  narrowness  in  the  diagonal  diameter  downward 
and  the  lack  of  compensating  gain  in  the  transverse  diameters,  this 
form  may  oppose  a  considerable  obstacle  to  the  passage  of  the  foetus. 
The  origin  of  this  form  of  pelvis  is  not  positively  known.  ■  Perhaps 
it  is  only  due  to  an  exaggeration  of  the  normal  process  by  which  the 
pelvis  of  the  new-born  is  changed  to  that  of  the  adult.  The  sacrum 
sinks  forward  and  downward  into  the  pelvic  cavity,  but  does  not 
rotate  around  its  transverse  axis.  Thus  the  anteroposterior  diameters 
are  shortened.  The  sacrum  being  bound  to  the  ilium  by  the  strong 
iliosacral  ligaments,  these  are  put  on  the  stretch,  which  would  tend 
to  open  the  pelvis  in  front.  This  being  ])revented  by  the  symphysis 
pubis  and  the  strong  ligaments  surrounding  it,  the  result  would  be  an 
increase  in  the  transverse  diameters,  and  when  this  is  not  found,  we 


DEFORMITIES    OF    THE    PELVIS. 


449 


must  attribute  it  to  some  degree  of  narrowness  in  the  original  con- 
struction of  the  pelvis. 

When  one  looks  at  the  hard,  thick  bones  of  the  pelvis  of  an  adult, 
it  is  difficult  to  realize  such  transmutations  of  shape,  but  we  must 
remember  that  during  childhood  a  large  portion  of  the  pelvic  bones 
is  still  cartilaginous  and  pliable  (Fig.  180,  p.  145),  and  even  in 
youth  the  sacral  vertebrae  are  still  united  by  cartilage.  The  union 
between  the  three  bony  nuclei  found  in  each  sacral  vertebra  takes 
place  from  the  second  to  the  sixth  year.  On  the  body  of  each  ver- 
tebra epiphyseal  plates  are  formed  after  puberty,  as  in  other  verte- 
brae, and  two  flat,  irregular  plates  of  bone  are  added  to  each  lateral 
surface  of  the  sacrum,  the    uppermost  of  which   extends  over  the 


Fig.  351. 


Ehachitic  flat  pelvis.    One-third  natural  size.    (Wood's  Museum,  Bellevue  Hospital,  No.  181.) 


auricular  surface  and  the  lower  over  the  sharp  edge  below.  These 
appear  about  the  eighteenth  year,  and  are  united  about  the  twenty- 
fifth.  The  bodies  of  the  sacral  vertebrae  are  first  united  by  interver- 
tebral disks.  Osseous  union  begins  from  below  and  extends  upward. 
This  process  commences  in  the  eighteenth  year  and  is  not  always 
finished  by  the  twenty-fifth.  The  ilium,  ischium,  and  pubis  do  not 
grow  together  before  the  seventeenth  or  eighteenth  year. 

Others  think  that  the  formation  of  the  simple  flat  pelvis  is  due  to  the 
mildest  degree  of  rhachitis,  a  degree  so  mild  that  it  did  not  leave  any 
other  trace  in  the  pelvis  and  the  rest  of  the  skeleton  than  this  flatness. 

2.  Rhachitic  Flat  Pelvis. — In  the  rhachitic  flat  pelvis  (Fig.  351) 
the  bones  commonly  are  thin  and  slender,  but  may  be  even  unusually 
thick  and  coarse.     They  are  small,  especially  the  ilium.     The  ilium 

29 


450 


ABNORMAL   LABOR. 


lies  more  horizontally.  It  is  flat,  its  crest  less  curved,  its  anterior 
superior  spines  stand  far  out,  so  that  the  distance  between  them 
sometimes  is  as  long  as  or  longer  than  that  between  the  crests.  The 
sacrum  is  small.  Its  transverse  curvature  is  nearly  lost.  Its  perpen- 
dicular curvature  varies  much.  In  most  cases  the  bone  is  more  or 
less  strongly  curved,  even  so  as  to  project  forward  like  a  hook  (Fig. 
352).  In  others,  on  the  contrary,  it  is  nearly  straight,  or  even  convex 
(Fig.  353).     The  bodies  of  its  vertebrae  are  strongly  compressed  from 


Fig.  352. 


Fig.  353. 


Rhachitic  flat  pelvis  with  strongly  curved 
sacrum.     (Tarnier  and  Budin,  1.  c.) 


Rhachitic  flat  pelvis  with  convex  sacrum. 
(Tarnier  and  Budin,  1.  c.) 


above  downward  behind  the  alse.  The  whole  bone  is  driven  forward 
and  downward,  and  the  bodies  of  the  vertebrae  have  sunk  down 
between  the  alse.  At  the  same  time  it  has  rotated  around  its  trans- 
verse axis,  so  as  to  approach  the  promontory  to  the  symphysis.  On 
the  other  hand,  the  symphysis  moves  backward  and  upward  in  the 
direction  of  the  promontory.  When  this  is  weh  marked  the  brim  of 
the  pelvis  approaches  the  shape  of  a  lying  figure  of  eight— oo.  The 
tuberosities  of  the  ischium  are  turned  outward  and  wide  apart.  The 
pubic  arch  is  large.  The  acetabulum  is  turned  more  forward  than 
normal.  The  whole  pelvis  in  most  cases  is  low,  the  cavity  wide,  but 
the  sacrocotyloid  distance  diminished.  The  transverse  diameters  are 
not  shortened  and  are  often  elongated.  The  inclination  of  the  pelvis 
is  considerable,  and  the  angle  formed  by  the  minimum  diameter  of  the 
brim  and  the  posterior  surface  of  the  symphysis  large.  In  computing 
the  true  diagonal  much  must  therefore  be  subtracted  from  the  diagonal 
conjugate.     Fig.  354  shows  a  rhachitic  pelvis  with  heart-shaped  brim. 


DEFORMITIES    OF    THE    PELVIS. 


451 


Rickets  is  a  constitutional  disease  of  childliood  characterized  by 
a  disorder  of  nutrition  of  the  bones.  The  osteoid  layer  between  the 
already  formed  bony  structure  and  the  cartilage  which  precedes  the 
bone  becomes  inflamed.  The  calcareous  matter  in  the  bones  is 
absorbed  and  the  tissue  is  full  of  inflammatory  corpuscles, — small, 
round  cells.  The  bones  become  soft  and  pliable,  and  bend  under 
the  influence  of  weight,  ligamentary  tension,  muscular  contraction, 
and  the  growth  of  internal  organs ;  and  certain  characteristic  changes 

Fig.  354. 


Rhachitic  pelvis  with  lieart-shaped  brim.     (Wood's  Museum,  Bellevue  Hospital,  No.  170.) 
Oue-third  actual  size. 


remain  permanently  in  the  skeleton  after  the  disease  has  run  its 
course  and  consolidation  has  taken  place,  as  shown  in  a  pronounced 
degree  in  Fig.  355. 

The  legs  become  curved,  the  pelvis  is  changed  as  described  above, 
the  vertebral  column  is  deviated,  the  lower  ribs  bulge  out  while  the 
upper  are  flattened  ;  the  breast-bone  protrudes,  forming  the  so-called 
chicken-breast ;  the  anterior  ends  of  the  ribs  are  swollen,  presenting  a 
line  of  nodules  known  as  the  rhachitic  rosary  ;  the  skull  is  large  and 
quadrangular,  contrasting  with  the  small  triangular  face.  On  the 
upper  extremities  the  thick  wrists  are  the  most  prominent  feature. 

Rhachitis  may  be  congenital,  but  most  frequently  makes  its  appear- 


452 


ABNORMAL   LABOR. 


ance  between  the  fourth  and  the  seventh  month  of  extra-uterine  hfe, 
at  a  period  when  the  child  has  not  yet  begun  to  walk,  or,  if  the  dis- 
ease breaks  out  later,  the  child  stops  walking  and  remains  lying  and 
sitting  up  in  bed.      The  peculiarities  of  the  rhachitic  pelvis  are  all 


Fig.  355. 


referable  to  the  softening  of 


the  bones,  pressure,  and  lack 
of  use  of  the  lower  extremi- 
ties. There  being  no  lateral 
pressure  from  the  femora,  the 
pelvic  form  is  decided  by  the 
weight  of  the  upper  half  of 
the  body  pressing  the  pos- 
terior wall  from  above  and 
behind  in  the  direction  of 
the  anterior.  The  tension 
upon  the  ligaments  behind 
and  in  front  draws  the  pelvic 
ring  out  to  the  sides,  making 
the  iliac  bones  gape  and  turn- 
ing the  acetabula  forward. 
When  later  the  child  begins 
to  walk,  the  pressure  of  the 
femora  will  only  increase  the 
flatness  of  the  pelvis.  The 
middle  part  of  the  sacrum  is 
pressed  in  between  the  lat- 
eral parts,  bringing  the  prom- 
ontory forward  and  down- 
ward, while  the  sacrosciatic 
ligaments  pull  the  lower  part 
of  the  bone  forward,  which 
results  in  the  common  strong 
perpendicular  curvature  of 
the  bone.  In  rarer  cases  the 
pressure  takes  such  a  direc- 
tion that  it  straightens  the 
bone  out  in  its  upper  part, 
but  the  lowest  nearly  always 
is  turned  forward.  The  tu- 
berosities are  spread  apart 
and  the  arch  flattened  chiefly 

by  pressure  against  the  couch,  and  secondarily  by  the  pull  of  the 

muscles  attached  to  their  outer  surface. 

Besides  these  mechanical  agencies  there   must  be  an  unknown 


Rhachitic  skeleton.     (Taraier  andBudin,  1.  c.) 


DEFORMITIES    OF    THE    PELVIS. 


453 


Fig.  356. 


force  at  work  in  the  rudimentary  beginnings  of  the  pelvis,  as  evinced 
by  the  shape  found  in  congenital  rhachitis. 

Rhachitis  gives  rise  to  the  highest  degrees  of  flat  pelvis,  producing 
pelves  that  have  a  true  conjugate  of  three  and  one-quarter  inches 
or  less. 

Mechanism  of  Labor  in  Flat  Pelvis. — Abnormal  presentations  are 
much  more  common  with  a  flat  pelvis,  be  it  rhachitic  or  not,  than  with 
a  normal  pelvis.  They  are  even  not  infrequent  in  primiparae,  who 
rarely  have  them  when  their  pelves  are  normal.  The  vertex  does  not 
engage  easily  and  slides  to  one  side,  which  leads  to  transverse  or  pelvic 
presentation ;  or,  the  occiput  hitching  against  the  rim  of  the  pelvis,  a 
face  or  brow  presentation  may  be  developed.  In  pelvic  presentations 
the  broad  buttocks  are  not  easily  engaged  and  let  the  smaller  feet 
sink  down  ahead.  With  presenting  head  there  is  a  tendency  to  pro- 
lapse of  a  hand,  an  arm,  a  leg,  or  the  cord  beside  the  head.  In  trans- 
verse presentations  the  dorsoposterior  position  is  much  more  frequent 
than  in  a  normal  pelvis. 

In  vertex  presentation  the  mechanism  is  quite  different  from  the  one 
we  have  seen  in  the  generally  contracted  pelvis.  The  head  stands 
transversely  over  the  brim.  The  occiput 
slides  to  one  side,  and  the  anterior  part  of 
the  vertex  with  the  large  fontanehe  sinks 
down.  The  head  passes  the  available  diame- 
ter of  the  brim  with  a  part  lying  a  little  in 
front  of  the  parietal  eminences  or  even  with 
the  bitemporal  diameter.  At  the  same  time 
the  head  becomes  laterally  inclined  so  that 
the  anterior  bregmatic  bone  nearly  occupies 
the  whole  brim  and  the  sagittal  suture  runs 
transversely  near  the  promontory  (Fig.  356). 
The  anterior  temple  is  pressed  against  the 
symphysis,  which  forms  a  fulcrum  around 
which  the  head  rotates,  the  anterior  parietal 
bone  being  more  and  more  bent,  while  the 
posterior  is  flattened  against  the  promontory 
and  gradually  is  pushed  down  into  the  pelvic  cavity.  When  the  head 
has  passed  the  narrow  brim,  the  occiput  generally  sinks  down  and 
turns  forward  as  in  a  normal  pelvis. 

Exceptionally,  it  is  the  posterior  parietal  bone  that  occupies  the 
brim,  the  sagittal  suture  runs  transversely  behind  or  above  the  sym- 
physis pubis,  and  the  posterior  temple  is  pressed  against  the  promon- 
tory. We  have  seen  above  that  a  similar  lateral  obliquity  of  the  head 
may  be  found  with  a  normal  pelvis  (p.  366 :  anterior  and  posterior 
parietal  presentations  and  ear  presentation).     This  posterior  parietal 


Engagement  of  vertex  in  flat 
pelvis.     (Olshausen-Veit.) 


454  ABNORMAL   LABOR. 

presentation  is  very  unfortunate,  since  the  engagement  of  the  head 
becomes  exceedingly  difficult  or  impossible  on  account  of  the  direc- 
tion of  the  uterus  forward.  The  neck  of  the  child  becomes  strongly 
bent  laterally  against  the  anterior  shoulder.  The  only  way  in  which 
the  head  can  pass  is  that  the  posterior  temple  is  pushed  down  under 
the  promontory,  and  that  subsequently  the  anterior  parietal  bone 
descends  behind  the  anterior  wall  of  the  pelvis. 

As  a  rule,  the  foetus  dies  during  the  tedious  labor,  and  even  the 
mother  is  in  great  danger  on  account  of  the  distention  of  the  posterior 
part  of  the  lower  uterine  segment. 

The  shajye  of  the  head  of  the  child  caused  by  the  passage  through 
a  flat  pelvis  is  characteristic.  The  occipitofrontal  diameter  becomes 
elongated  and  the  transverse  diameters  become  shortened.  The  sero- 
sanguinolent  swelling  constituting  the  caput  succedaneum  is  gener- 
ally found  on  the  anterior  part  of  the  vertex,  especially  if  the  latter 
part  of  labor  has  been  so  rapid  that  no  swelling  has  formed  on  the 
occiput.  Pressure  marks  are  mostly  found  on  the  parietal  bone,  and 
are  particularly  produced  by  the  promontory.  They  take  the  shape 
of  round  or  oval  spots  or  a  stripe  running  parallel  with  and  behind 
the  coronal  suture  from  the  large  fontanelle  to  the  temple,  or  form- 
ing an  angle  opening  forward  (Fig.  360).  We  shall  reserve  details 
about  the  moulding  of  the  head  and  pressure  marks  for  further  con- 
sideration. 

In  rare  cases  the  head  is  observed  to  go  dowm  in  another  way 
than  the  one  described  as  characteristic  for  labor  with  flat  pelvis, — 
namely,  so  that  only  one  side  of  the  pelvic  brim  is  used  for  the  pass- 
age of  the  head.  This  extramedian  engagement  is  most  likely  to  occur 
in  pelves  of  the  figure-of-eight  shape,  in  which  the  promontory  is  very 
prominent  and  the  symphysis  pubis  projects  inw^ard  into  the  pelvic 
cavity.  Then  the  head  passes  as  in  the  generally  equally  contracted 
pelvis,  wdth  the  small  fontanelle  low  down.  When  the  brim  is  passed, 
the  position  of  the  head  becomes  normal. 

Face  presentation  is,  as  we  have  said,  more  frequently  encountered 
than  in  normal  pelves.  The  course  of  labor  is  very  slow,  the  face 
continuing  to  stand  transversely,  the  chin  at  one  end  and  the  forehead 
at  the  other  end  of  the  transverse  diameter.  It  takes  long  before  the 
chin  rotates  forward,  and  the  prognosis  for  the  child  is  even  worse 
than  with  vertex  presentation. 

The  pelvic  presentation,  on  the  other  hand,  is  somewhat  more 
favorable  for  the  child,  since  the  aftercoming  head  engages  with  less 
difficulty  than  the  presenting  vertex.  Still  the  process  is  so  slow  that 
without  the  intervention  of  art  the  foetus  generally  dies,  and  it  even 
often  does  so  wdien  its  head  is  being  pulled  through  artificially. 

Transverse  presentations   usually  end   as    shoulder   presentations. 


DEFORMITIES    OF   THE    PELVIS.  455 

Labor  is  still  more  difficult  than  in  a  normal  pelvis  with  this  presenta- 
tion, and  ought  never  to  be  left  to  nature. 

The  diagnosis  of  a  simple  flat  pelvis  is  based  on  the  results  of  pel- 
vimetry and  the  low  position  of  the  large  fontanelle.  The  flat  rha- 
chitic  pelvis  is  recognized  by  the  same  features  combined  with  those 
peculiar  to  rhachitis.  The  history  may  give  a  hint.  If  the  patient  did 
not  begin  to  walk  before  she  was  two  years  old,  it  is  likely  she  was 
suffering  from  rickets.  Next,  the  degree  of  contraction  is  of  diagnostic 
importance.  The  higher  degrees  of  narrowness — a  true  conjugate  of 
3|^  inches  (8  centimetres)  or  less — are  found  only  with  rhachitis. 
Finally,  the  characteristic  shape  of  the  rhachitic  pelvis,  the  compara- 
tively long  distance  between  the  anterior  superior  spines  of  the  ilium, 
the  flatness  of  the  iliac  bones,  and  signs  of  rhachitis  in  other  parts  of 
the  body — the  thick  wrists,  the  prominent  breast-bone,  the  flattened 
ribs,  and  the  short,  curved  lower  extremities — remove  every  doubt  in 
regard  to  the  origin  of  the  disease. 

Difficult  labor  is  much  more  common  in  pluriparae  with  narrow 
pelves  than  in  primiparas,  which  is  attributable  to  a  weakness  in  the 
uterine  wall  left  by  previous  labors.  This  favors  abnormal  presenta- 
tions and  attitudes  of  the  child,  and  causes  weak  contraction  of  the 
muscle-fibres.  Pendulous  abdomen,  which  leads  to  an  unfavorable 
presentation,  is  also  much  more  common  in  pluriparae.  And,  on  the 
other  hand,  the  fetal  head  becomes  larger  in  successive  pregnancies. 

Course  of  Labor  in  Flat  Pelvis. — Labor  is  apt  to  be  very  slow, 
even  protracted  over  several  days,  which  tediousness  is  not  all  due 
directly  to  the  mechanical  disproportion  between  the  head  of  the 
foetus  and  the  mother's  pelvis.  Other  factors — slow  dilatation  of 
the  OS  and  weakness  of  the  uterine  contractions — contribute  to  this 
result. 

The  slow  dilatation  is  itself  due  partly  to  this  weakness  of  uterine 
contractions,  and  partly  to  the  common  occurrence  of  premature  rup- 
ture of  the  membranes,  a  fact  that  may  find  its  explanation  in  the  less 
perfect  adaptation  between  the  presenting  part  and  the  pelvic  brim, 
which  allows  a  greater  amount  of  liquor  amnii  to  accumulate  below 
the  foetus.  By  the  premature  rupture  of  the  membranes  the  normal 
elastic  pressure  of  the  bag  of  waters  against  the  cervix  during  the  open- 
ing stage  is  lost,  and  the  cervical  muscular  tissue  becomes  irritated  by 
compression  between  the  head  and  the  pelvis. 

When  the  waters  have  broken  and  theos  is  still  small,  uterine  con- 
traction may  push  the  foetus  into  the  lower  uterine  segment  and  the 
cervix,  which  become  much  distended  and  so  thin  that  they  may  give 
way.  The  contraction  ring  is  drawn  high  up  and  may  be  seen  at  the 
level  of  the  umbilicus. 

The  undilated  cervix  in  other  cases  becomes  oedematous,  and,  as  we 


456  ABNORMAL   LABOR. 

have  seen  above,  the  anterior  Up  is  especially  exposed  to  being  caught 
between  the  advancing  head  and  the  symphysis  pubis. 

Uterine  contractions  may  be  primarily  weak  and  often  become  so 
secondarily,  the  nerve  force  being  exhausted  by  the  abnormal  amount 
of  work  the  uterus  is  called  upon  to  perform  in  order  to  overcome 
the  obstacle  that  obstructs  the  passage. 

In  other  cases  the  uterus  becomes  permanently  contracted  around 
the  foetus, — tetanus  uteris — which  opposes  an  almost  insuperable  resist- 
ance to  obstetrical  operations. 

The  mechanical  disproportion  may  be  so  great  that  the  presenting 
part,  particularly  the  head,  does  not  engage  at  all ;  but  in  the  majority 
of  cases  the  head,  through  a  slow  process  of  moulding,  adapts  itself  to 
the  pelvis.  This  work  is  done  exclusively  by  uterine  contraction, 
while  the  beginning  of  abdominal  pressure  is  a  signal  that  the  mould- 
ing has  been  perfected  and  that  the  head  is  about  to  pass  the  brim  of 
the  pelvis.  Two  other  symptoms  herald  the  same  event, — namely,  a 
sudden  desire  to  defecate,  although  the  rectum  is  empty,  and  a  cramp 
in  the  calves  produced  by  pressure  on  the  sacral  plexus. 

During  this  process  of  moulding  there  is  often  formed  on  the  pre- 
senting part  of  the  head  a  caput  succedaneum,  which  may  mislead  the 
accoucheur,  inducing  him  to  take  the  serosanguineous  swelling  which 
bulges  out  on  the  head  for  the  bony  head  itself,  and  to  think  that  this 
has  descended  while  in  reality  it  is  still  above  the  brim. 

When  the  head  has  passed  the  brim,  labor  becomes  easy  in  those 
cases  of  flat  pelvis  in  which  the  narrowness  is  limited  to  that  part  of 
the  pelvis. 

§  3.  Generally  Contracted  Flat  Pelvis. — The  generally  contracted 
flat  pelvis  combines  the  characteristics  of  the  generally  contracted  and 
the  flat  pelvis.  It  is  a  flat  pelvis  in  which  the  transverse  diameter  is 
shortened  beside  the  anteroposterior  diameter. 

This  form  of  pelvis  is  nearly  always  of  rhachitic  origin. 

The  diagnosis  may  be  difficult  and  is  mostly  based  on  the  way  in 
which  the  foetus  passes,  which  is  a  combination  of  the  mechanism  in 
generally  contracted  and  flat  pelves.  In  most  cases  the  head  stands 
transversely  as  in  the  flat  pelvis,  and  the  small  fontanehe  stands  low  ; 
but  often  the  anterior  part  of  the  vertex  and  the  occiput  alternate  in 
their  descent,  so  that  at  times  the  small  fontanelle  and  at  others  the 
large  occupy  the  lowest  position  in  the  pelvis.  In  this  form  of  pelvis 
the  extramedian  engagement  of  the  head — the  forehead  remaining 
high  in' the  iliac  fossa  while  the  occiput  descends  through  one-half  of 
the  pelvis — is  also  frequent. 

§  4.  Pelvis  Flattened  by  Dislocation  of  both  Femora. — Before 
leaving  the  flat  pelvis  we  must  mention  a  peculiar  form  due  to  the 
congenital  dislocation  of  both  femora  (Fig.  357). 


DEFORMITIES    OF    THE    PELVIS. 


457 


This  pelvis  is  cliaracterized  by  flatness,  a  great  inclination,  and 
considerable  increase  in  the  length  of  the  transverse  diameter 
throughout  the  pelvis.  The  sacrum  has  sunk  deep  in  between  the 
hip-bones.  The  ilium  is  steep.  The  pubic  arch  is  very  open  and 
the  tuberosities  of  the  ischia  are  turned  outward.  The  transverse 
diameter  of  the  outlet  is  much  enlarged,  Avhile  the  anteroposterior  is 
shortened. 

The  head  of  the  femur  resting  on  the  outer  surface  of  the  ilium 
pushes  it  up  into  the  more  perpendicular  position.  The  deep  posi- 
tion of  the  sacrum  increases  the  transverse  dimensions  and  dimin- 

FiG.  357. 


:J 


Pelvis  with  dislocation  of  both  femora.     (Olshausen-Veit.) 


ishes  the  conjugate,  and  there  is  no  counter-pressure  against  the 
acetabula  to  counterbalance  this  influence.  At  the  outlet  the  pro- 
tracted sitting  posture,  necessitated  by  the  inability  to  walk  in  early 
childhood,  contributes  to  the  large  span  of  the  arch  and  the  great 
distance  between  the  tuberosities. 

The  great  inclination  of  the  pelvis  is  due  partly  to  the  pull  on  the 
strong  iliofemoral  ligament  and  the  psoas  and  iliacus  internus  mus- 
cles, partly  to  the  removal  backward  of  the  points  of  support.  The 
heads  of  the  femora  being  pushed  backward,  the  upper  portion  of 
the  body  would  fall  forward  if  the  lumbar  portion  of  the  vertebral 


458  ABNORMAL   LABOR. 

column  were  not  curved  forward,  carrying  the  upper  portion  of  the 
body  backward,  and  this  lordosis  again  increases  the  inclination  of 
the  pelvis. 

In  regard  to  mechanism  of  labor,  prognosis,  and  treatment,  this 
pelvis  is  much  like  the  flat  rhachitic  pelvis. 

§  5.  Dangers  for  the  Mother  in  Cases  of  Contracted  Pelvis. — 
Any  form  of  contracted  pelvis  exposes  the  mother  to  more  or  less 
danger,  and  the  greater  the  contraction  is  the  more  the  peril  increases. 
The  soft  parts  suffer  through  the  pressure  to  which  they  are  exposed. 
In  this  respect  vertex  presentations  are  the  worst,  the  head  being 
harder  than  the  breech.  The  soft  parts  stand  a  severe  pressure  a 
short  time  much  better  than  a  more  moderate  pressure  that  extends 
over  a  longer  period.  The  protracted  pressure  of  the  vertex  therefore 
does  more  harm  than  the  rapid  passage  of  the  after-coming  head  when 
it  is  pulled  through  by  the  obstetrician. 

The  pressure  against  the  promontory  is  particularly  harmful.  In 
easier  cases  it  may  cause  only  a  local  inflammation,  but  in  severer  ones 
it  may  result  in  gangrene  of  the  uterus.  Before  complete  mortifica- 
tion sets  in,  the  part  is,  however,  surrounded  by  adhesive  inflamma- 
tion, which  encapsulates  the  dead  tissue  and  prevents  the  peritoneal 
cavity  from  being  opened,  but  may  lead  to  permanent  adhesion  of  the 
uterus. 

In  front  the  bladder,  situated  between  the  cervix  and  the  symphysis, 
is  exposed  to  pressure,  which  often  results  in  the  formation  of  a 
urinary  fistula. 

The  disproportion  between  the  head  and  the  pelvis  may  cause  the 
rupture  of  one  or  more  of  the  articulations  of  the  pelvis,  most  fre- 
quently the  symphysis  pubis.  The  rupture  of  the  symphysis  is  char- 
acterized by  local  pain,  diastasis  between  the  ends  of  the  pubic  bones, 
and  rotation  outward  and  lameness  of  the  lower  extremities. 

The  protracted  labor,  the  frequent  examinations,  and  necessary 
operations  increase  the  danger  of  infection.  Gas  may  be  produced 
by  microbes  in  the  uterine  cavity  and  distend  it  so  that  the  fundus 
reaches  the  diaphragm,  a  condition  called  physometra  or  tympania 
uteri.  Percussion  gives  then  a  tympanitic  sound.  Offensive  gases 
may  escape  during  examinations  or  after  the  expulsion  of  the  foetus. 
Frequently  the  patient  becomes  feverish. 

Independently  of  the  danger  of  infection,  the  patient's  strength  is 
liable  to  give  out.     She  is  worn  out  by  pain  and  physical  exertion. 

The  pressure  on  the  soft  parts  is  apt  to  cause  inflammation.  If 
there  are  strong  uterine  contractions  and  the  resistance  is  insuperable, 
the  lower  uterine  segment  and  the  cervix  may  rupture. 

The  pressure  on  the  sacral  plexus  may  lead  to  paralysis,  contrac- 
ture, or  protracted  neuralgia  in  the  lower  extremities. 


DEFORMITIES    OF   THE    PELVIS.  459 

The  operations  performed  in  order  to  deliver  the  patient  may  be- 
come dangerous  to  her.  Thus  version,  when  the  lower  uterine  seg- 
ment and  the  cervix  are  much  distended,  may  directly  lead  to  the 
rupture  of  these  parts  of  the  uterus. 

The  forceps  may  do  great  harm,  not  only  if  it  is  applied  outside 
•of  the  cervix,  which  it  crushes  and  tears,  but  even  if  it  is  applied 
through  an  insufficiently  dilated  cervix.  The  accommodation  of  the 
head  to  the  pelvis  obtained  by  hauling  on  it  with  the  forceps  cannot 
be  compared  with  that  accomplished  by  nature  by  means  of  uterine 
contractions,  and  the  maternal  tissues  are  therefore  exposed  to  most 
injurious  pressure.  Symphyseotomy  and  Caesarean  section  contain 
dangers  of  their  own  which  we  shall  describe  later. 

Pelvic  presentation  is  more  favorable  to  the  mother  than  vertex 
presentation.  The  breech  presses  less  than  the  head,  and,  as  a  rule, 
this  latter  will  be  helped  out  with  or  without  perforation. 

Transverse  presentations  are  very  serious  if  they  are  neglected, 
but  if  they  are  discovered  in  time  and  treated  intelligently,  they  are 
not  much  worse  for  the  mother  than  in  normal  pelves. 

§  6.  Dangers  for  the  Foetus  in  Contracted  Pelvis. — If  labor  with 
a  contracted  pelvis  is  fraught  with  dangers  to  the  mother,  it  is  still 
more  so  in  regard  to  the  foetus. 

The  strong  uterine  contractions  that  are  necessary  to  overcome 
the  obstacle  placed  in  its  way  in  a  narrow  pelvis  may  in  different 
ways  hurt  the  foetus.  The  blood  is  pressed  out  of  the  uterus  and 
into  the  maternal  vessels,  so  that  there  is  less  to  carry  oxygen  to 
the  placenta.  This  organ  may  be  prematurely  detached,  which  di- 
rectly induces  asphyxia  of  the  foetus.  The  same  results  from  com- 
pression of  the  umbilical  cord,  which  is  common  in  narrow  pelves. 
The  strong  compression  to  which  the  skull  is  exposed  may  cause 
irritation  of  the  pneumogastric  nerve,  which  renders  the  heart-beat 
slow.  It  also  plays  a  chief  role  in  the  changes  observed  in  the 
shape  of  the  head.  We  have  already  mentioned  the  caput  succeda- 
neum  which  forms  on  the  part  that  is  least  exposed  to  pressure,  but 
it  does  so  only  by  the  compression  of  the  surrounding  portions  of 
the  head.  In  equally  generally  contracted  pelvis,  in  most  cases  of  flat 
generally  contracted  pelvis,  and  in  cases  of  extramedian  engagement 
the  caput  forms  as  in  labor  in  a  normal  pelvis  around  the  small 
fontanelle.  In  the  flat  pelvis  it  develops,  on  the  contrary,  in  the 
region  of  the  anterior  fontanelle.  It  is  innocuous  in  itself  and  dis- 
appears a  few  days  after  delivery.  It  may  even  be  useful  to  the 
mother  by  replacing  the  missing  bag  of  waters  and  helping  to  dilate 
the  cervix,  but  it  may  give  the  accoucheur  the  erroneous  idea  that 
the  head  has  descended  when  in  reality  it  is  still  detained  at  the 
brim.      It  can,  however,  easily  be  distinguished  from  the  skull  by 


460  ABNORMAL   LABOR. 

the  softness  of  its  structure,  especially  in  the  interval  between  uterine 
contractions. 

The  bones  of  the  skull  are  pushed  over  and  under  one  another 
and  are  bent,  transpositions  and  deformations  which,  if  they  are 
moderate,  need  not  have  any  bad  effect,  and  which  disappear  in  a 
few  days  after  the  birth  of  the  child.  Apart  from  all  moulding,  in 
labor  with  normal  pelvis,  and  even  on  the  head  of  the  children 
brought  to  the  world  by  Ctesarean  section,  there  is  a  physiological 
congenital  asymmetry  of  the  head.  It  is  a  kind  of  scoliosis  of  the  verte- 
brae, of  which  the  skull  is  composed  originally.  The  right  temple 
and  the  corresponding  portion  of  the  base  of  the  skull  are  more 
prominent  than  on  the  left  side,  while  on  the  occiput  is  found  a 
prominence  somewhere  to  the  left  of  the  median  line  and  a  lesser 

Fig.  358. 

Fig.  359. 


^' 


Deep  depressions  on  presenting  head.  Deep  depressions  on  after-coming  head. 

(Olshausen-Veit.)  (Olshausen-Veit.) 

prominence  or  even  a  flattening  to  the  right.  It  is  also  well  known 
that  there  is  considerable  difference  between  the  two  sides  of  the 
head  in  adults. 

If  the  limits  of  adaptability  of  sutures  and  bones  are  passed,  the 
head  sustains  injuries  which  even  may  be  fatal.  Sutures  may  be  torn 
and  the  underlying  sinuses  wounded,  especially  the  superior  longi- 
tudinal sinus  when  the  parietal  bones  are  displaced,  and  the  trans- 
verse sinus  when  the  temporal  bone  is  torn  loose  from  the  parietal, 
which  is  most  apt  to  happen  when  the  after-coming  head  is  dragged 
through  a  narrow  pelvis.  The  condylar  portions  of  the  occipital  bone 
are  sometimes  torn  from  the  tabular  portion. 

The  bones  themselves  may  be  broken.  So-called  fissures  form 
in  the  direction  of  the  osseous  fibres.  They  may  be  distinguished 
from  gaps  due  to  insufficient  ossification  by  their  bloody  edges.  In 
the  tabular  portion  of  the  occipital  bone  such  a  transverse  fracture  is 
often  found  corresponding  to  the  line  of  union  between  the  pieces  of 
bone  that  are  formed  from  different  points  of  ossification. 


DEFORMITIES    OF   THE    PELVIS. 


461 


Another  form  of  fracture  is  found  in  the  so-called  depressions 
(Figs.  358,  359).  These  depressions  are  found  on  the  parietal  and 
frontal  bones,  and  may  be  produced  by  mere  uterine  contractions, 
but  often  they  are  due  to  the  use  of  the  obstetric  forceps.  Half  of 
the  children  die  during  or  shortly  after  birth.  In  those  who  survive 
the  depressions  may  be  obliterated,  but  often  they  remain  through 
life.  Sometimes  they  cause  idiocy  or  other  disturbances  of  the 
nervous  system,  but  in  other  cases  the  children  recover  entirely  and 
do  not  show  any  ill  effect  of  the  injury  sustained  during  labor. 


Fig.  360. 


Pressure  marks  on  the  skin  of  the  skull  and  face  of  new-born  children.    (Fritsch  and  Kiistuer.) 


By  these  tears  and  breaks  more  or  less  blood  is  poured  out  on 
the  surface  of  the  brain.  In  many  instances  it  is  again  absorbed, 
but  if  it  compresses  the  meduDa,  or  if  the  loss  of  blood  is  large,  the 
foetus  succumbs.  When  the  forehead  sinks  low  down,  the  orbit  may 
be  exposed  to  such  a  pressure  that  its  temporal  wall  is  depressed  and 
the  eye  pushed  out — exophthalmus. 

We  find  also  pressure  marks  on  the  soft  tissues  of  the  head. 
They  may  be  mere  round  or  oval  spots  or  long  stripes  (Fig.  360). 
They  may  be  only  superficial  scratches,  and  then  they  are  pink.  Or 
the  pressure  may  have  gone  deeper  and  lasted  longer,  when  they  have 


462  ABNORMAL   LABOR. 

a  purple  color.  If  the  pressure  has  been  still  more  considerable^ 
the  whole  layer  of  soft  tissue,  inclusive  of  the  periosteum,  may  be 
mortified.  In  this  case  the  dead  tissue  is  eliminated  and  the  gap 
filled  by  granulation,  while  the  more  superficial  traces  regain  their 
normal  color  and  structure.  These  pressure  marks  correspond  chiefly 
to  the  promontory,  but  more  rarely  similar  marks  may  be  found  on 
the  other  side  of  the  head,  where  they  are  due  to  a  projecting  sym- 
physis. Still  less  frequently  they  ar6  left  by  the  spine  of  the  ischium 
or  other  projecting  thorns  and  lines.  In  some  pelves  the  pubic  por- 
tion of  the  iliopectineal  line  is  as  sharp  as  a  knife,  or  a  bony  thorn  is 
found  in  the  attachment  of  the  psoas  minor  muscle.  Such  pelves 
have  been  described  under  the  name  of  thorn-pelves^  but  they  are 
found  as  well  in  males  as  in  females. 

Besides  the  head,  other  portions  of  the  foetus  may  suffer  injury 
during  labor.  In  the  upper  part  of  the  sternocleidomastoid  muscle  is 
sometimes  found  a  hcematoma.  This  collection  of  blood  forms  a  small, 
hard  tumor  in  the  second  week  after  birth.  It  is  usually  due  to 
rupture  of  muscular  fibres  caused  by  the  manual  extraction  of  the 
head  or  by  the  application  of  the  forceps,  but  it  has  also  been  found 
after  easy  normal  labor,  and  is  then  attributed  to  intra-uterine  disease 
of  the  muscle.  Applications  of  arnica  and  massage  further  the  resolu- 
tion of  the  swelling. 

Fracture  of  the  humerus  is  generally  due  to  carelessness  in  the 
liberation  of  the  arms  in  manual  extraction.  If  the  accoucheur,  in- 
stead of  following  the  rule  to  advance  until  he  reaches  the  elbow 
before  trying  to  bring  the  arm  down,  places  his  thumb  as  a  fulcrum 
on  the  middle  of  the  humerus  and  two  fingers  spread  on  the  other 
side,  he  exposes  this  slender  bone  in  the  highest  degree  to  the  danger 
of  being  fractured.  But  if  there  is  any  difficulty  in  reaching  the  elbow 
or  otherwise  bringing  the  arm  down,  and  the  child's  life  is  in  danger, 
it  is  better  to  extract  a  live  child  with  a  broken  arm,  that  by  proper 
care  heals  in  two  weeks,  than  to  let  the  child  die. 

Fracture  of  the  collar-bone  and  the  cervical  vertebrae  occurs  also. 
As  a  rule,  it  may,  however,  be  avoided  by  taking  care  always  to  turn 
the  back  of  the  child  in  the  direction  in  which  the  occiput  is,  so  as  to 
avoid  torsion  of  the  neck. 

Of  a  somewhat  similar  nature  to  fractures  is  the  loosening  of  the 
epiphyses  of  the  long  bones,  which  may  also  happen. 

Paralysis  of  the  upper  extremities  is  mostly  due  to  lesion  of  the 
cervical  plexus.  It  arises  particularly  in  consequence  of  the  liberation 
of  the  arms  in  pelvic  presentation.  Sometimes  the  injury  is  hmited 
to  the  radial  or  the  ulnar  nerve.  In  other  cases  there  is  a  more 
complex  paralysis  of  the  infraspinatus,  the  brachialis  anticus,  and  the 
rotatory  muscles,  an  affection  produced  by  pressure  on  the  sixth  cer- 


DEFORMITIES    OF   THE    PELVIS.  463 

vical  nerve  and  known  as  Erh^s  paralysis.     Such  nerve  lesions  should 
at  an  early  date  be  treated  with  electricity. 

§  7.  Treatment  of  Labor  in  Plat  and  Generally  Contracted 
Plat  Pelvis. — In  discussing  the  treatment  to  be  followed  in  labor 
obstructed  by  a  flat  pelvis  it  is  convenient  to  keep  in  mind  the  division 
of  the  narrowness  into  three  degrees  referred  to  above  (p.  436),  two 
of  which  are  again  subdivided  into  two  groups'. 

Class  I.  First  degree.  True  conjugate  3|-4  inches  (9-10  cen- 
timetres). 

Class  II.  Second  degree.  True  conjugate  2|—3^  inches  (7-9  cen- 
timetres). 

Group  a.  True  conjugate  near  3^-  inches  (9  centimetres). 
Group  b.  True  conjugate  near  3  inches  (7^  centimetres). 
Class  III.  Third  degree.     True  conjugate  below  2J  inches  (7  cen- 
timetres). 

Group  a.  True  conjugate  2-2|  inches  (5-7  centimetres). 
Group  b.  True  conjugate  below  2  inches  (5  centimetres).  • 
In  the  first  degree,  where  the  length  of  the  true  conjugate  is  not 
below  3|  inches  (9  centimetres)  in  a  flat  pelvis  (or  3|  inches — 9| 
centimetres — in  a  generally  contracted  flat  pelvis)  the  contraction  is 
evinced  only  by  the  peculiar  position  occupied  by  the  head.  In  this 
mildest  degree  of  contraction  labor  may  proceed  without  the  inter- 
ference of  art,  or  if  it  is  necessary  to  expedite  delivery  on  account  of 
the  condition  of  the  mother  or  the  foetus,  as  a  rule  the  extraction  by 
forceps  is  indicated. 

No  less  clear  is  the  line  of  conduct  to  be  chosen  by  the  accoucheur 
in  the  highest,  the  third,  degree  of  contraction,  where  the  true  conju- 
gate is  less  than  2|  inches  (7  centimetres).  If  the  true  conjugate 
measures  below  2  inches  (5  centimetres),  Caesarean  section  should  be 
performed  at  once,  whether  the  foetus  is  dead  or  alive,  for,  although 
the  fcetus  has  been  broken  up  and  delivered  through  a  narrower 
pelvis,  the  danger  to  the  mother  is  much  greater  than  in  modern 
Caesarean  section. 

If  the  true  conjugate  measures  between  2  and  2f  inches  (5-7  cen- 
timetres), Caesarean  section  should  only  be  performed  when  the  foetus 
is  alive.     If  it  is  dead,  craniotomy  is  indicated. 

In  the  intervening  second  class  of  narrow  pelves,  whose  true  con- 
jugate measures  between  2|  and  3^  inches  (7-9  centimetres),  a  good 
deal  of  judgment  may  be  needed,  as  we  have  to  choose  between  ver- 
sion, forceps,  and  symphyseotomy.  This  class,  like  the  third,  may 
conveniently  be  subdivided  into  two  groups.  2|-  inches  (7  centimetres) 
is  the  shortest  true  conjugate  that  will  allow  the  passage  of  a  living 
child,  and  this  is  possible  only  under  favorable  circumstances — good 
uterine  contractions,  a  full-sized  transverse  diameter,  and  a  small 


464  ABNORMAL   LABOR. 

head.  The  first  group  comprises  those  pelves  whose  true  conjugate 
is  near  3J  inches  (9  centimetres),  and  the  second  those  whose  true 
conjugate  is  near  3  inches  {7^  centimetres). 

If  there  is  a  cross  presentation  or  a  face  or  brow  presentation,  tlie 
foetus  should  be  turned  and  extracted.  But  if  there  is  a  vertex  or 
breech  presentation  and  a  conjugate  of  3 J  inches  (9  centimetres),  one 
may  expect  that  a  majority  of  labors  will  end  favorably  and  perhaps 
even  without  artificial  intervention.  We  should  therefore  give  nature 
ample  scope.  We  should  let  the  uterine  contraction  have  plenty  of 
time  to  open  up  the  cervix,  but  if  needed,  we  may  help  the  dilatation 
by  means  of  chloral,  antipyrin,  or  Barnes's  and  Champetier  de  Ribes's 
dilators,  a  colpeurynter,  or  manual  dilatation  by  Harris's  or  Bonnaire's 
method.  (See  Operations.)  We  may  further  the  engagement  of 
the  head  by  direct  pressure  through  the  abdominal  wall  on  the  occi- 
put and  the  chin  of  the  fastus.  When  the  os'  is  fully  dilated  the 
membranes  should  be  ruptured,  so  as  to  give  the  uterine  contrac- 
tions a  chance  to  mould  the  presenting  head.  If  the  abdomen  is 
pendulous,  the  uterus  should  be  raised  and  kept  in  proper  position 
by  means  of  a  binder.  A  hypodermic  injection  of  morphme  may 
relieve  pain,  produce  sleep,  and  give  the  flagging  uterine  contrac- 
tions new  strength.  If  necessary,  labor  is  ended  by  means  of  the 
forceps.  In  rare  cases  it  may  be  necessary,  in  order  to  gain  room 
for  the  application  of  the  forceps,  to  incise  the  not  fully  dilated 
cervix.  If  the  foetus  is  dead,  the  head  is  first  diminished  with  the 
perforator. 

In  case  of  danger  to  mother  or  foetus  demanding  prompt  delivery, 
labor  is  ended  by  version  if  the  head  yet  is  freely  movable  over  the 
brim  of  the  pelvis,  or  by  forceps  if  the  head  is  well  engaged.  But  the 
forceps  seizes  the  head  over  the  occiput  and  forehead  and  by  com- 
pression will  increase  the  size  of  the  transverse  diameters  of  the  head. 
Too  great  strength  should  not  be  used,  for  fear  of  injuring  both  mother 
and  foetus.  Under  such  circumstances  the  man  who  is  limited  to  his 
own  resources  will  do  better  in  having  recourse  to  the  perforator, 
whether  the  foetus  is  dead  or  alive.  He  who  has  the  necessary  assist- 
ance, and  especially  those  who  operate  in  hospitals,  should  substitute 
symphyseotomy  when  the  foetus  is  alive,  and  reserve  the  perforator 
for  a  dead  foetus. 

In  pelvic  presentations  it  is  advisable  early  in  labor  to  bring  down 
one  of  the  feet,  so  as  to  have  something  to  take  hold  of  and  avoid 
an  impaction  of  the  breech  with  legs  extended  in  front  of  the  foetus. 

When  the  genital  tract  has  been  sufficiently  dilated  by  the  breech, 
the  foetus  should  be  extracted.  In  helping  the  head  out  the  accouch- 
eur should  pull  in  the  direction  in  which  the  head  stands  in  the  pelvis, 
and  not  try  to  change  its  position,  which  is  likely  to  increase  the  dif- 


DEFORMITIES   OF   THE    PELVIS.  465 

Acuities  of  its  passage.  The  back  of  the  child  should  be  held  so  as  to 
correspond  to  the  occiput,  in  order  to  avoid  torsion  of  the  vertebral 
column,  which  may  cause  fracture  of  bones,  rupture  of  ligaments,  and 
compression  of  the  medulla. 

We  come  now  to  the  second  group  of  the  second  class  of  pelves, 
those  where  the  true  conjugate  is  in  the  neighborhood  of  three  inches 
(7|  centimetres).  If  the  vertex  presents,  we  have  to  choose  between 
early  version  and  extraction  on  one  side  and  expectant  treatment 
followed  by  the  forceps  and  perhaps  symphyseotomy  or  Csesarean 
section  on  the  other.  The  last-named  operation  should  be  chosen 
only  in  the  beginning  of  a  labor  and  when  it  is  certain  that  no  infec- 
tion has  taken  place.  Otherwise  the  prognosis  becomes  too  serious. 
It  is  a  clinical  experience  that  women  will  bear  symphyseotomy  after 
examinations  have  been  instituted  with  proper  precautions  and  an 
attempt  made  to  deliver  with  forceps.  Not  so  with  Caesarean  section, 
in  regard  to  which  it  makes  the  greatest  difference  whether  the  case 
is  aseptic  at  the  time  of  operation.  The  condition  of  the  foetus  must 
also  be  considered :  if  that  has  suffered  through  delay  or  the  use  of 
the  forceps,  Caesarean  section  is  preferable  to  symphyseotomy  in  so 
far  as  it  offers  almost  instantaneous  relief. 

If  delivery  cannot  be  accomplished  with  the  forceps  with  a  reason- 
able display  of  strength,  if  the  outer  circumstances  permit  it,  and  if 
the  foetus  is  alive,  symphyseotomy  is  indicated. 

In  regard  to  the  use  of  version  and  extraction  early  in  labor  opin- 
ions are  divided.  It  has  been  contended  that  the  base  of  the  skull, 
being  narrower  than  the  vertex,  accommodates  itself  more  easily  to 
the  brim  of  the  pelvis.  The  after-coming  head  has  plenty  of  room 
to  bulge  upward,  but  a  presenting  vertex  is  pressed  right  against  the 
obstruction  and,  as  it  were,  flattened  out.  On  the  other  hand,  there 
is  this  difference, — that  with  presenting  vertex  the  head  may  have 
hours  and  even  days  to  conform  to  the  shape  of  the  pelvis,  while 
in  extraction  by  the  feet  the  accommodation  must  take  place  within 
a  few  minutes  or  the  foetus  will  die.  The  expeditious  delivery  is 
particularly  difficult  in  a  primipara  whose  parturient  canal  is  narrow 
and  not  prepared  for  the  passage  of  the  foetus.  Often  version  is 
impossible,  because  the  waters  have  drained  off,  the  uterus  is  tetani- 
cally  contracted  around  the  foetus,  and  the  cervix  not  dilated.  In 
other  cases,  again,  the  cervix  and  lower  uterine  segment  may  be  so 
distended  that,  by  introducing  hand  and  arm,  the  accoucheur  might 
bring  about  a  rupture  of  these  parts.  But  if  the  membranes  are  un- 
ruptured, or  at  least  recently  ruptured,  good  results  may  bo  obtained 
by  version  and  extraction. 

The  following  rules  are  based  on  a  large  experience  in  lying-in 
hospitals.     Version  is  indicated  : 

30 


466  ABNORMAL   LABOR. 

1.  When  any  danger  for  mother  or  foetus  necessitates  speedy 
delivery  at  a  time  when  the  fcetus  is  still  freely  movable  above  the 
pelvic  brim.  Such  conditions  are,  especially  in  regard  to  the  mother, 
hemorrhage,  exhaustion,  cessation  of  uterine  contractions,  or  fever, 
and  in  regard  to  the  foetus  slow,  weak  heart  sounds,  and  expulsion 
of  meconium. 

2.  In  cases  of  face  presentation,  brow  presentation,  or  transverse 
presentation, 

3.  With  a  prolapse  of  the  umbilical  cord. 

4.  In  a  flat  pelvis  with  a  true  conjugate  of  3:^  inches  (8  centi- 
metres) if  experience  in  former  labors  has  shown  that  the  patient  had 
a  particularly  hard  time  or  even  gave  birth  to  dead  children. 

5.  In  asymmetric  pelves. 

If,  besides  the  shortenmg  of  the  anteroposterior  diameter,  there  is 
some  diminution  of  the  transverse  diameter,  a  pelvis  with  a  true  con- 
jugate of  3 1  inches  (8  centimetres)  practically  becomes  one  of  the 
second  class,  second  group. 

On  the  other  hand,  if  the  child  is  premature  or  small,  a  pelvis 
with  a  true  conjugate  of  3  inches" or  a  little  less  (7  J  centimetres)  may 
be  looked  upon  as  belonging  to  the  second  group  of  the  first  class. 

If  during  the  manipulations  of  version  the  foetus  dies,  the  after- 
coming  head  should  be  perforated,  which  may  be  done  through  the 
spinal  canal,  an  excellent  method  by  which  the  mother  is  protected 
against  all  danger  of  being  wounded. 

If  in  the  first  group  of  the  third  degree  of  coarctation  (a  pelvis 
with  true  conjugate  2-2f  inches — from  5  to  7  centimetres)  the  foetus 
is  dead  and  movable  above  the  brim,  it  should  be  turned  and  its 
head  perforated  through  the  spinal  canal.  If  the  head  is  impacted, 
it  is  perforated  through  the  vertex.  If  the  foetus  is  alive  and  per- 
foration is  decided  upon,  the  same  rules  are  to  be  followed.  But 
it  should  be  explained  to  the  mother  that  she  may  give  her  child  a 
chance  of  life  by  submitting  to  CaBsarean  section.  Still,  if  she  is  in 
too  low  a  condition  to  stand  the  shock  of  this  operation,  it  is  more 
humane  to  sacrifice  the  foetus  and  try  to  save  the  mother,  or,  if  the 
conjugate  is  between  2J  and  8  inches  (6|  and  7J  centimetres),  to 
perform  symphyseotomy. 

In  pelvic  presentations  the  treatment  is  the  same  as  that  described 
above  for  the  first  degree  and  the  first  group  of  the  second  degree, — 
that  is  to  say,  to  bring  down  a  foot,  extract,  and,  if  necessary,  to 
perforate. 

In  cases  of  posterior'  ear  presentation,  it  is  best  to  introduce  the 
whole  hand,  seize  the  head  and  rotate  it  around  the  fronto-occipital 
diameter,  so  as  to  bring  the  sagittal  suture  back  towards  the  promon- 
tory.    If  this  does  not  succeed,  version  should  be  performed ;  but  if 


DEFORMITIES    OF    THE    PELVIS.  467 

the  lower  uterine  segment  and  the  cervix  are  too  tense,  the  head  must 
be  perforated. 

We  have  seen  above  (p.  273)  that  if  the  condition  of  the  pelvis  is 
known  during  pregnancy,  it  is  better  to  induce  premature  labor  in  a 
pelvis  whose  true  conjugate  measures  between  2|-  and  3|-  inches  (7-9 
centimetres). 

Artificial  abortion  has  been  resorted  to  in  cases  in  which  the  true 
conjugate  is  so  short — less  than  2|  inches  (7  centimetres) — that  a  via- 
ble fcetus  cannot  be  pulled  through  the  genital  canal.  But,  as  we  have 
stated  above  (p.  269),  many  are  opposed  to  this  operation  on  moral 
or  religious  grounds,  and  think  the  woman  should  take  her  chances 
with  Csesarean  section. 

In  regard  to  hunger  cure,  in  the  hope  of  preventing  dangerous 
operations,  the  reader  is  referred  to  what  has  been  said  on  page  274. 

B.  Rarer  Deformities  of  the  Pelvis. 

§  1.  Asymmetric  Pelvis. — Pelves  whose  sacrocotyloid  distance, 
which  normally  measures  about  3^  inches  (9  centimetres),  differs 
materially  on  the  two  sides  are  called  asymmetric. 

This  class  comprises  three  kinds  of  pelves, — (1)  the  scoliotic  pelvis, 
(2)  the  obliquely  contracted  pelvis,  or  Naegele  pelvis,  and  (3)  the 
coxalgic  pelvis. 

1.  The  Scoliotic  and  the  Scoliotic-R.hachitic  Pelvis. — Scoliosis 
has  obstetric  importance  only  when  the  sacrum  is  implicated  in  it. 
The  most  common  seat  of  the  scoliosis  is  in  the  dorsal  portion  of 
the  vertebral  column,  and  is  generally  turned  with  the  convexity 
towards  the  right  side.  It  is  in  general  compensated  by  a  lateral  cur- 
vature in  the  opposite  direction  in  the  lumbar  portion  of  the  column 
and  has  little  or  no  influence  on  the  pelvis.  The  scoliosis  that  is 
so  common  in  girls  after  puberty  and  is  caused  by  weak  mus- 
cular development  or  an  habitual  faulty  position,  occurs  at  a  time 
when  the  pelvis  has  lost  much  of  the  flexihility  which  characterizes 
it  during  childhood,  and  has  therefore  little  influence  on  it  compared 
with  that  of  rhachitis.  The  form  that  opposes  considerable  ob- 
stacle to  the  passage  of  the  foetus  is  nearly  always  of  rhachitic  origin 
(Fig.  361). 

This  pelvis  has  the  common  characters  of  a  rhachitic  pelvis,  but 
offers  besides  some  peculiarities.  The  sacrum  is  transversely  flat  or 
even  convex,  and  the  whole  bone  is  rotated  on  its  longitudinal  axis 
in  such  a  way  that  the  promontory  is  turned  to  the  narrow  half  of  the 
pelvis,  generally  the  left.  The  narrow  side  corresponds  indeed  always 
to  the  side  where  the  convexity  of  the  lumbar  curve  is.  The  narrow- 
ness is  found  chiefly  at  the  brim,  but  extends  often   more  or  less 


468 


ABNORMAL   LABOR. 


through  the  whole  pelvis.  The  sacrocotyloid  distance  is  diminished 
on  the  side  towards  which  the  sacrum  is  turned,  and  so  is  the  oblique 
diameter  of  the  opposite  side,  while  the  oblique  diameter  of  the  narrow 
side  is  lengthened.  The  ilium  of  the  narrow  side  is  pushed  inward, 
upward,  and  backward,  so  that  it  stands  more  perpendicularly.  The 
corresponding  ala  of  the  sacrum  is  narrow.  The  symphysis  pubis  is 
pushed  over  to  the  opposite  side. 

Minor  degrees  of  this  deformity  are  not  rare  and  do  not  interfere 
seriously  with  childbirth,  but  sometimes  one  side  of  the  pelvis  is 


ScoMotic-rhachitic  pelvis.     (Patay.) 


reduced  to  a  mere  gutter  and  counts  for  nothing  from  an  obstetric 
stand-point.  The  pelvis  is  then  virtually  a  generally  contracted  pelvis, 
the  sacrocotyloid  distance  of  the  wide  side  representing  the  true  con- 
jugate and  the  oblique  diameter  corresponding  to  the  transverse 
diameter, 

2.  The  Obliquely  Contracted  Pelvis,  or  Naegele  Pelvis. — The 
distinctive  feature  of  a  Naegele  pelvis  (Fig,  362)  is  the  atrophy  of  one 
lateral  mass  of  the  sacrum.    As  a  rule,  there  is  also  a  synostosis  of  the 


DEFORMITIES   OF   THE    PELVIS. 


469 


iliosacral  joint  of  the  same  side,  and  the  superior  strait  of  the  pelvis 
forms  an  oblique  oval,  the  narrow  end  of  which  lies  at  the  atrophic  ala. 

Minor  degrees  of  this  deformity  are  probably  not  very  rare,  and 
are  often  overlooked  because  they  do  not  give  rise  to  obstetrical  diffi- 
culties ;  but  the  higher  degrees  are  decidedly  rare  and  have  been 
minutely  described  by  some  of  the  greatest  obstetricians. 

One  lateral  mass  of  the  sacrum  is  little  developed,  in  some  cases 
so  much  so  that  the  ilium  almost  joins  the  bodies  of  the  original  verte- 

FiG.  362. 


Oblique!}-  contracted,  ankylosed  pelvis,  or  Naegele  pelvis.    (Wood's  Museum,  Bellevue 
Hospital,  No.  173.)     One-third  actual  size. 


brae  composing  the  sacrum.  The  sacral  foramina  of  this  side  and  the 
auricular  surface  if  it  exists,  or  else  the  area  that  would  correspond  to 
it,  are  much  smaller  than  those  of  the  other  side.  The  anterior  sur- 
face of  the  bone  is  rotated  around  its  longitudinal  axis  in  the  direc- 
tion of  the  diseased  side.  The  promontory  looks  the  same  way,  and 
the  lumbar  portion  of  the  vertebral  column  is  scoliotic  with  the  con- 
vexity turned  in  the  same  direction.  With  the  lateral  curvature  is,  as 
always,  combined  a  torsion  so  that  the  bodies  are  rotated  in  the  direc- 


470  ABNORMAL   LABOR. 

tion  of  the  atrophic  side  and  consequently  the  spinous  processes  in 
the  opposite  direction.  Tlie  spinous  process  of  the  last  lumbar  ver- 
tebra is  therefore  approximated  to  the  posterior  superior  spine  of  the 
ilium  on  the  healthy  side. 

The  symphysis  is  pushed  over  to  the  opposite  side.  The  iliopec- 
tineal  line  is  straightened  on  the  diseased  side  and  more  curved  than 
normal  on  the  healthy  side.  The  sacrocotyloid  distance  is  shortened 
on  the  affected  side  and  lengthened  on  the  healthy  one.  On  the  other 
hand,  the  oblique  diameter  of  the  diseased  side  is  lengthened  and  that 
of  the  healthy  one  shortened.  Thus  the  entrance  of  the  true  pelvis 
has  the  shape  of  an  egg  placed  obliquely,  with  the  broad  end  turned 
forward  in  the  healthy  side  and  the  narrow  end  backward  at  the 
defective  ala  and  the  sacro-iliac  articulation. 

In  consequence  of  the  deviation  in  opposite  directions  of  the  prom- 
ontory and  the  symphysis  pubis,  the  true  conjugate  is,  as  a  rule, 
lengthened.  The  transverse  diameter,  on  the  contrary,  is  shorter  than 
normal.  The  narrowness  often  extends  through  the  pelvis  and  espe- 
cially the  transverse  diameter  is  diminished.  The  hip-bone  is  pushed 
inward,  upward,  and  in  most  cases  backward.  Generally  there  is  a 
synostosis  between  this  bone  and  the  sacrum,  and  the  line  of  union 
is  marked  by  a  smooth,  bony  ridge.  The  acetabulum  is  displaced 
upward  and  turned  more  forward.  The  pubic  arch  is  shorter  on  the 
affected  side  and  its  gap  is  turned  in  this  direction.  The  tuberosity 
and  the  spine  of  the  ischium  are  nearer  to  the  sacrum  and  the  sciatic 
notch  smaller  than  on  the  healthy  side. 

Having  thus  described  the  form  of  the  Naegele  pelvis  as  the  obstet- 
rician and  anatomist  find  it  in  the  grown-up  woman,  we  shall  try  to 
understand  how  these  numerous  changes  are  brought  about.  The 
starting-point  seems  to  be  an  original  deficiency  in  the  lateral  mass  of 
the  sacrum  due  to  lack  of  development,  the  falling  out  of  some  points  of 
ossification.  This  would  lead  to  the  lumbar  scohosis  and  an  obliquity 
of  the  pelvis  by  which  the  acetabulum  is  turned  more  downward, 
whereby  it  is  exposed  to  greater  pressure,  the  effect  of  which  is  to 
bring  the  hip-bone  farther  inward,  upward,  and  backward,  which  again 
explains  all  the  other  changes. 

In  other  cases  inflammation  in  the  articulation  seems  to  have  been 
the  first  disease,  which  later  led  to  the  atrophy  of  the  sacrum.  Path- 
ologists are  driven  to  the  conclusion  that  there  has  been  a  primary 
iliosacral  arthritis  by  the  predominating  signs  of  an  old  inflammation, 
which  doubtless  has  been  suppurative  and  may  have  started  during 
intra-uterine  life  or  after  birth.  Such  signs  of  inflammation  as  oste- 
ophytes, fistulous  tracts,  or  cicatrices,  are  found  at  the  articulation  and 
in  its  neighborhood.  But  also  at  a  distance  are  often  found  oste- 
ophytes on  the  sacrum  and  the  hip-bone. 


DEFORMITIES    OF    THE    PELVIS.  471 

The  condition  of  the  sacro-iliac  articulation  craves  particular  atten- 
tion. In  some  cases  it  may  never  have  existed.  The  defect  that 
caused  the  poor  development  of  the  lateral  mass  of  the  sacrum  may 
have  involved  the  place  where  the  articulation  between  the  two  bones 
should  have  been  formed  in  fetal  life.  By  progressive  ossification  the 
two  bones  melted  together  and  the  result  was  a  congenital  synostosis 
instead  of  an  articulation.  Such  a  primary  ossification  must  be  sup- 
posed to  have  taken  place  in  pelves  in  which  there  is  no  backward 
displacement  of  the  ilium. 

In  most  cases,  however,  this  displacement  backward  is  manifest, 
and  proves  that  the  bones  were  bound  together  in  a  way  allowing 
some  degree  of  mobility.  In  these  cases  the  theory  is  that  the  press- 
ure on  the  acetabulum  caused  an  inflammation,  either  of  a  purulent 
or  an  adhesive  character,  of  the  sacro-iliac  joint,  which  led  in  course  of 
time  to  the  destruction  of  the  articulation  and  a  secondary  synostosis. 
The  inflammation  of  the  joint  may  take  a  very  chronic  and  painless 
course. 

In  rarer  cases,  again,  the  articulation  was  preserved  and  no  synos- 
tosis followed.  On  the  other  hand,  synostosis  may  be  found  in  the  rha- 
chitic  asymmetric  pelvis.  It  is  therefore  no  criterion  of  the  Naegele 
pelvis.  A  synostosis  may  occur  later  in  the  life  of  the  woman,  but  that 
has  little  influence  on  the  form  of  the  pelvis  and  is  therefore  without 
obstetric  interest. 

At  the  seat  of  the  synostosis  the  texture  of  the  bone  is  dense  and 
hardened.  The  foramina  nutritia  may  be  diminished,  which  would 
interfere  with  the  nutrition  of  the  bone,  and  result  in  a  secondary 
atrophy  of  the  corresponding  lateral  mass  of  the  sacrum.  This,  again, 
would  lead  to  the  above-described  changes  in  the  shape  of  the  pehis 
and  the  vertebral  column. 

3.  CoxALGic  Pelvis. — When  for  some  reason  an  individual  cannot 
during  childhood  make  use  of  one  of  the  lower  extremities,  or  only 
uses  it  imperfectly,  the  weight  of  the  body  shifts  over  on  the  opposite 
side,  and  the  healthy  extremity  exercises  so  strong  a  pressure  that  the 
pelvis  becomes  asymmetric ;  but  in  this  case  the  oblique  oval  formed 
by  the  superior  strait  has  its  broad  end  on  the  diseased  side  (Fig.  363). 
The  oblique  diameter  of  this  side  is  shortened  (opposite  to  what  takes 
place  in  a  Naegele  pelvis).  The  obliquity  extends  in  most  cases 
through  the  pelvic  cavity.  The  most  common  affection  that  causes 
this  form  of  pelvis  is  coxitis  ;  but  inflammation  of  the  knee-joint,  dis- 
location of  the  femur,  infantile  paralysis,  the  amputation  of  the  limb, 
may  have  the  same  etfect.  All  that  is  required  is  that  the  affection 
appears  in  childhood,  while  the  pelvis  is  still  soft,  and  that  it  lasts  for 
some  length  of  time. 

If  the  child — e.g.,  in  congenital  dislocation   of  the  femur — rests 


472 


ABNORMAL   LABOR. 


more  on  the  diseased  side  than  on  the  healthy  side,  the  oval  is  turned 
the  other  way.  Then  this  half  of  the  pelvis  becomes  the  narrower 
one.  The  same  will  be  the  result  if  the  healthy  extremity  is  not  used 
at  all  and  there  is  some  atrophy  of  the  bones  of  the  diseased  side. 

There  is  also  a  scoliosis,  and,  as  a  rule,  the  convexity  turns  to  the 
healthy  side,  but  there  are  exceptions.     Generally,  the  pressure  on  the 


Coxalgic  pelvis.     (Wood's  Museum,  Bellevue  Hospital,  Xo.  178.)     One-third  actual  size. 


acetabulun  produces  some  atrophy  of  the  lateral  mass  of  the  sacrum 
on  the  same  side  in  which  the  narrowing  occurs. 

The  outlet  is  often  distorted.  The  tuberosity  on  the  healthy  side, 
like  the  rest  of  the  hip-bone,  is  pressed  upward  and  inward,  while  that 
on  the  diseased  side  is  pulled  outward  by  traction  from  the  muscles 
originating  on  it. 

In  the  coxalgic  pelvis  the  asymmetry  is  not  so  great  as  in  the 


DEFORMITIES    OF   THE    PELVIS.  473 

Naegele  pelvis,  and  therefore  it  does  not  oppose  such  dangerous 
obstacles  to  delivery.  As  a  rule,  the  head  passes  without  much  diffi- 
culty with  its  occipitofrontal  diameter  through  that  part  of  the  pelvis 
that  has  the  longer  of  the  two  oblique  diameters  of  the  brim,  and  the 
outlet  is  wide  from  side  to  side,  even  if  it  is  contracted  in  the  antero- 
posterior diameter. 

Diagnosis  of  Asymmetric  Pelves. — In  any  woman  who  limps  the 
pelvis  should  be  carefully  examined.  Certain  external  measures  may 
be  of  value  in  this  respect.  The  most  important  is  the  distance 
between  the  spinous  process  of  the  fifth  lumbar  vertebra  and  the 
posterior  superior  spine  of  the  ilium.  Especially  in  Naegele's  pelvis 
this  is  much  shorter  on  the  healthy  side.  Another  measure  is  taken 
from  the  anterior  superior  spine  of  the  ilium  on  one  side  to  the 
posterior  superior  spine  of  the  same  bone  on  the  other  side,  which 
distance  normally  measures  8J  inches  (21  centimetres).  A  third 
measurement  is  the  distance  from  the  anterior  superior  spine  of  the 
ilium  to  the  spinous  process  of  the  fifth  lumbar  vertebra,  which  nor- 
mally is  7  inches  (18  centimetres).  A  fourth  measure  is  that  from 
the  lower  end  of  the  symphysis  pubis  to  the  posterior  superior  spine 
of  the  ilium,  which  normally  is  about  6  inches  (15  centimetres).  The 
difference  on  the  two  sides  must  be  marked,  A  difference  of  less 
than  half  an  inch  (one  centimetre)  in  these  measures  is  without  diag- 
nostic value. 

The  internal  examination  must  be  carried  out  with  the  half  or  the 
whole  hand.  By  it  we  feel  the  spine  of  the  ischium  to  be  nearer  to 
the  edge  of  the  sacrum  on  one  side  than  on  the  other  and  that  the 
iliopectineal  line  is  straighter  on  one  side.  We  feel  the  promontory 
turned  to  one  side  and  the  symphysis  to  the  other.  In  some  cases 
we  find  the  anterior  and  posterior  walls  of  the  pelvis  on  one  side  so 
approximated  to  each  other  that  there  is  between  them  only  a  narrow 
gutter  without  obstetric  value. 

Prognosis. — The  prognosis  in  asymmetric  pelves  depends  more  on 
the  size  of  the  pelvis  than  on  its  oblicj[uity.  Still,  in  the  higher  degrees 
of  obliquity  it  is  quite  serious.  Of  the  three  kinds  of  asymmetric 
pelves  we  have  distinguished,  the  Naegele  pelvis  with  its  defective 
sacrum  is  most  dangerous  and  the  coxalgic  the  least  so.  The  pelvic 
presentation  is  bad  for  the  child,  but  favorable  for  the  mother,  in  so 
far  as  labor  will  be  terminated  earlier  by  perforation,  and  thus  the 
great  pressure  on  her  soft  parts  avoided. 

The  mechanism  of  labor  is  peculiar  and  the  knowledge  of  it  of  great 
importance  for  the  treatment  to  be  adopted.  In  moderate  degrees  of 
contraction  the  head  may  pass  with  its  occipitofrontal  diameter  either 
through  the  narrow  or  through  the  wide  side  of  the  pelvis.  The  diffi- 
culty arises  from  the  broad  occiput.     If  there  is  room  enough  for  the 


474  ABNORMAL   LABOR. 

narrower  forehead  to  pass  through  the  narrow  side,  this  offers  the 
advantage  that  the  occipitofrontal  diameter  of  the  head  coincides  with 
the  longer  oblique  diameter  of  the  pelvis.  But  if  the  coarctation  is  so 
great  that  the  forehead  cannot  pass,  the  pelvis  practicaUy  becomes  a 
generally  contracted  pelvis,  and  the  best  chance  is  for  the  head  to 
engage  in  the  shorter  oblique  diameter  of  the  pelvis. 

When  the  head  passes  through  the  narrow  side  of  the  pelvis,  the 
occiput  sinks  deep  down  so  as  to  substitute  the  shorter  suboccipito- 
bregmatic  for  the  longer  occipitofrontal  diameter,  and  the  sagittal 
suture  approaches  the  conjugate  diameter  even  at  the  entrance  of  the 
pelvis.  When  the  head  enters  the  wide  side,  the  occiput  may  take 
the  same  position,  but  this  is  not  always  the  case,  and  the  shortened 
obhque  diameter  of  the  pelvis  may  then  offer  too  great  resistance  for 
the  descent  of  the  head. 

At  the  outlet  the  head  passes  with  least  difficulty  if  the  sagittal 
suture  goes  through  the  shorter  oblique  diameter. 

In  pelvic  presentations  the  head  passes  most  easily  when  the  broad 
occiput  is  in  the  wide  part  of  the  pelvis. 

Treatment— U  the  patient  is  seen  during  pregnancy,  premature 
labor  should  be  induced  if  the  true  conjugate  is  less  than  three  and 
three-quarters  inches  (9i  centimetres).  But  if  the  contraction  is  very 
great,  Csesarean  section  may  be  the  only  way  of  saving  the  child's  life. 
If  the  child  is  dead,  it  should  be  turned,  and  the  aftercoming  head  per- 
forated. In  the  minor  degrees  of  narrowness,  it  is  best  to  wait  and 
let  the  head  descend  some  if  the  occiput  is  turned  forward  and  the 
head  stands  in  the  longer  obhque  diameter,  and  then  help  it  out  with 
the  forceps.  If  it  does  not  yield  to  reasonable  force,  it  should  be 
perforated. 

If  the  head  does  not  engage,  or  if  the  occiput  turns  backward,  or 
if  the  head  stands  in  the  shorter  obhque  diameter,  it  is  best  to  turn 
the  child  in  such  a  way  as  to  bring  the  broad  occiput  down  through 
the  wide  part  of  the  pelvis  and  the  forehead  through  the  narroAV  part, 
in  the  longer  oblique.  It  is  possible  to  do  this  because  the  foot  we 
pull  on  will  turn  forward  under  the  pubic  arch. 

If  we  do  not  succeed  with  forceps  or  version,  perforation  must 

follow. 

In  a  case  of  Naegele  pelvis  ischiopubiotomy  has,  however,  been 
performed  successfully  for  mother  and  child.     (See  Operations.) 

§  2.  Transversely  Contracted  Pelvis. — We  come  now  to  a  class 
of  pelves  where  the  contraction  is  not  found  in  the  anteroposterior, 
hut  in  the  transverse  direction. 

To  this  class  belong,  1,  the  ankylosed  transversely  contracted  pelvis 
and,  2,  the  kyphotic  pelvis,  to  which  is  nearly  related,  3,  the  funnel- 
shaped  pelvis. 


DEFORMITIES    OF   THE    PELVIS. 


475 


1.  The  Ankylosed  Transversely  Contracted  Pelvis. — This  form 
of  pelvis  is  characterized  by  the  ankylosis  of  both  the  sacro-iliac 
articulations  (Fig.  364).  It  is,  so  to  say,  a  double  Naegele  pelvis, — the 
atrophy  of  the  sacrum  and  the  synostosis  with  the  ilium  are  found 
on  both  sides ;  and,  as  in  the  Naegele  pelvis,  it  may  originate  in  the 
defective  bone  formation  or  in  the  inflammation  of  the  joint.  It  may 
be  congenital  or  acquired.  It  is  so  rare  that  only  half  a  score  of  cases 
have  been  reported. 

The  alee  of  the  sacrum  are  either  altogether  absent  or  in  a  very 
rudimentary  condition.     The  bodies  of  the  sacral  vertebrae  are  also 

Fig.  364. 


Ankylosed  transversely  contracted  pelvis,  or  Robert  pelvis.    (Wood's  Museum  Bellevue 
Hospital,  No.  166, )    One-third  actual  size. 


narrow,  and  the  anterior  surface  of  the  bone,  instead  of  being  hollow, 
presents  a  convexity  from  side  to  side.  In  most  of  the  few  cases 
known  of  this  deformity,  the  sacrum  is  situated  low  between  the  hip- 
bones. The  posterior  superior  spines  of  the  ossa  ilium  stand  much 
closer  to  each  other  than  normal.  These  bones  stand  more  perpen- 
dicularly. The  iliopectineal  line  is  little  curved,  nearly  straight.  At 
the  symphysis  pubis  it  forms  an  acute  angle.  The  true  conjugate  is 
not  much  shortened  or  may  even  be  longer  than  normal,  but  all  the 
transverse  diameters  are  greatly  diminished.  At  the  outlet  it  measures 
only  between  1  and  2|  inches  (2|-6  centimetres),  and  the  branches 
of  the  pubic  arch  run  nearly  parallel  to  each  other. 

In  the  first  pelvis  of  this  kind  known,  the  Robert  pelvis  in  Wurz- 


476  ABNORMAL   LABOR. 

burg,  the  peculiar  shape  of  the  pelvis  was  referable  to  an  injury 
sustained  when  the  patient  was  six  years  old  and  was  run  over  by  a 
wagon.  In  this  case  and  in  one  other — the  Landouzy  pelvis — the 
sacrum  has  not  sunk  down  between  the  hip-bones.  In  these  cases 
the  bone  had  already  a  fixed  position  at  the  time  the  injury  occurred. 
It  w^as  simply  arrested  in  its  growth  and  the  inflammation  in  the 
sacro-iliac  articulation  caused  by  the  injury  resulted  in  synostosis. 

In  the  other  cases  the  sacrum  is  found  situated  deep  in  the  pelvis. 
Here  the  process  took  place  at  a  time  when  the  pelvis  was  yet  soft  and 
flexible.  The  sacrum  was  pressed  down  by  the  weight  of  the  upper 
part  of  the  body.  This  would  of  itself  tend  to  a  tension  and  enlarge- 
ment of  the  brim  in  a  transverse  direction,  but,  the  alae  being  absent, 
this  effect  was  not  very  marked.  On  the  other  hand,  pressure  against 
acetabula  contributed  to  the  transverse  narrowness  of  the  pelvis.  The 
descent  of  the  sacrum  would  make  the  true  conjugate  shorter,  but 
this  is  counterbalanced  by  the  lateral  compression,  which  would  force 
the  symphysis  pubis  forward  and  thus  increase  the  length  of  the  true 
conjugate. 

Etiology. — As  with  the  Naegele  pelvis,  in  most  cases  the  starting- 
point  is  to  be  sought  in  an  original  lack  of  development  of  the  sacrum, 
and  when  we  find  this  on  both  sides,  and  as  a  congenital  condition, 
we  can  hardly  fail  to  see  it  in  the  light  of  atavism,  such  transverse 
narrowness  being  unusual  in  the  higher  animals.  The  lack  of  devel- 
opment and  the  abnormal  pressure  that  followed  when  attempts  at 
walking  were  made  resulted  in  inflammation  of  the  joint  and  synos- 
tosis. In  other  cases,  as  in  those  of  Robert  and  Landouzy,  the  in- 
flammation was  primary  and  led  to  the  synostosis  and  the  atrophy. 
In  others  again  the  synostosis  was  there  from  the  beginning,  no  articu- 
lations having  been  formed  in  fetal  life. 

Diagnosis. — The  diagnosis  of  a  transversely  contracted  pelvis  is 
easy.  It  is  based  on  external  measurements  and  internal  examina- 
tion. All  the  transverse  measures — the  distance  between  the  trochan- 
ters, the  anterior  superior  spines,  the  crests,  and  the  posterior  superior 
spines  of  the  ilium — are  shortened.  The  posterior  surface  of  the  sa- 
crum is  sunk  so  deep  in  between  the  ilia  that  the  spinous  processes 
can  hardly  be  felt.  At  the  internal  examination  one  is  struck  by  the 
narrowness  of  the  pubic  arch  and  the  straight  course  of  the  iliopec- 
tineal  line. 

Prognosis. — The  prognosis  is  bad.  No  viable  human  foetus  can  be 
born  through  a  transversely  contracted  pelvis. 

Treatment. — The  only  rational  treatment  consists  in  Caesarean 
section. 

2.  Kyphotic  Pelvis. — Kyphosis,  or  forward  curvature  of  the 
spine,  has  in  most  cases  little  influence  on  labor.     It  is  an  old  expe- 


DEFORMITIES    OF   THE    PELVIS. 


477 


rience  that  hunchbacks  have  easy  labors.  This  is  because  the  common 
seat  of  the  giJDbosity  is  high  up  in  the  dorsal  part  of  the  A^ortebral  col- 
umn, which  is  compensated  by  a  lordosis  of  the  lumbar  portion  of 
the  column.  In  this  way  the  pelvis  may  escape  all  influence  from 
the  distortion  of  the  spine.  In  order  to  produce  a  kyphotic  pelvis 
the  disease  in  the  spine  must  be  situated  lower  down.  The  purest 
type  of  kyphotic  pelvis  is  found  with  kyphosis  in  the  lumbar  region. 
Furthermore,  the  disease  must  have  made  its  appearance  at  an  early 
age,  when  the  pelvis  was  still  very  flexible. 

The  kyphotic  pelvis  is  characterized  by  a  large  entrance  and  a 
narrow  outlet.     The  author  has  given  a  detailed  description  of  one 

Fig.  365. 


Kyphotic  pelvis  seen  from  ab(i\  i 


ilie  front.    (Author's  case.) 


of  a  patient  whom  he  delivered  by  Ceesarean  section  in  preantiseptic 
times*  (Figs.  365-366). 

Ordinarily  the  sacrum  is  long,  narrow,  strongly  curved  from  side 
to  side,  at  least  in  its  lower  part,  and  straight  from  above  downward, 
while  sometimes  the  upper  part  is  convex  from  side  to  side.  It  is 
rotated  on  its  transverse  axis  so  that  the  base  sinks  back  between  the 
iliac  bones  and  the  apex  forward.  The  inclination  of  the  pelvis  is  very 
small.     The  hip-bones  are  turned  on  an  axis  riimiingin  an  aiiteropos- 

1  Garrigues,  "The  Improved  Cajsarean  Section,  containing  the  Description  of 
a  Kyphotic  Pelvis,"  Amer.  Jour.  Obst.,  April,  May,  June,  1883. 


478 


ABNORMAL    LABOR. 


terior  direction,  so  that  the  false  pelvis  becomes  large  and  the  outlet 
of  the  true  pelvis  narrow  from  side  to  side.  The  brim  of  the  pelvis 
is  large,  especially  the  true  conjugate.  The  shape  of  the  outlet  varies 
according  to  the  seat  of  the  kyphosis.  In  lumbodorsal  kyphosis  the 
conjugate  may  be  normal,  or  even  elongated,  but  in  lumbosacral  it  is 
always  shortened.  The  side  wall  of  the  pelvis  is  high.  The  pubic 
arch  is  narrow,  the  symphysis  pubis  is  situated  high  and  pushed 
forward.  In  the  neighborhood  of  the  iliopectineal  eminence  the  bone 
is  much  thickened.  The  ihopectineal  line  is  less  curved  than  normal. 
The  spine  of  the  ischium  is  turned  sharply  inward.     The  posterior 

Fig.  366. 


Kyphotic  pelvis  seen  from  behind  and  below.    (Author's  case.) 

superior  spines  of  the  ossa  ilium  are  nearer  to  each  other  than  normal 
and  project  less. 

The  mechanism  by  which  these  abnormalities  in  the  shape  of  the 
kyphotic  pelvis  are  produced  is  pretty  well  understood.  The  primary 
cause  is  a  caries  of  one  or  more  vertebrae.  When  the  corpus  of  the 
vertebra  is  consumed,  the  weight  of  the  superincumbent  portion  of 
the  whole  body  causes  the  column  to  bend  forward,  forming  an  angle 
at  the  diseased  part.  The  stooping  produced  in  this  way  would  be 
highly  inconvenient  and  fatiguing,  and  instinctively  the  patient  obviates 
the  evil  by  carrying  the  head  and  the  upper  part  of  the  trunk  back- 
ward, whereby  a  lordosis  is  formed  compensating  the  kyphosis  sit- 


DEFORMITIES    OF   THE    PELVIS.  479 

uated  lower  down.  Through  the  changed  pressure  the  base  of  the 
sacrum  is  tipped  back  and  its  apex  forward,  whereby  the  conjugate  of 
the  brim  of  the  pelvis  is  elongated  and  that  of  the  outlet  would  be 
shortened  if  there  were  not  other  factors  that  counterbalance  this 
effect.  At  the  same  time  a  compression  from  side  to  side  takes  place 
in  the  bone,  the  broadest  part  of  the  base,  which  is  situated  in  front, 
being  squeezed  in  between  the  posterior  ends  of  the  iliac  bones,  which 
are  nearer  together  than  the  width  of  the  sacrum,  the  result  of  which 
is  the  strong  transverse  curvature  and  the  narrowness  of  this  bone. 
The  stretching  in  the  longitudinal  direction  of  the  sacrum  is  doubtless 
due  to  the  fact  that  pressure  from  above  strikes  its  upper  end  under 
a  more  favorable  angle,  and,  therefore,  works  with  more  power  on 
that  than  on  the  part  situated  nearer  the  transverse  axis  around 
which  the  bone  is  being  tilted,  the  strong  ligaments  between  the 
sacrum  and  the  ilium  opposing  a  powerful  resistance  to  the  simple 
pushing  back  of  the  sacrum  in  toto. 

We  have  seen  that  the  stooping  of  the  body  was  obviated  by  a 
corresponding  lordosis  formed  above  the  seat  of  the  kyphosis,  but 
still  another  means  is  brought  into  action  in  order  to  bring  the  body 
into  a  more  favorable  relation  to  the  ground  when  the  individual  is 
in  the  upright  position.  The  whole  pelvis  is  tilted  backward,  turning 
on  an  axis  which  goes  through  both  hip-joints.  This  movement  can 
only  be  executed  by  the  contraction  of  the  glutei-maximi  muscles. 
But  this  backward  tilting  finds  a  check  in  the  strong  iliofemoral  liga- 
ment. This  ligament  being  constantly  put  on  the  stretch  explains  the 
development  of  the  iliopectineal  eminence  and  the  adjacent  mass  of 
bone  on  which  that  ligament  is  inserted.  The  frecfuent  abnormal  con- 
traction of  the  gluteus-maximus  muscle  draws  down  the  posterior  part 
of  the  ilium  and  makes  it  protrude  as  a  convexity  on  the  upper  sur- 
face. When  the  base  of  the  sacrum  is  tilted  back,  the  strong  sacro- 
iliac ligaments  are  stretched  and  pull  the  posterior  part  of  the  ilium 
backward.  The  combined  effect  of  the  contracted  glutei  maximi 
muscles  behind  and  the  strained  iliofemoral  ligament  in  front  is  to 
push  the  head  of  the  femur  inward  and  upward.  Hereby  the  os  in- 
nominatum  is  stretched  and  its  component  parts  are  brought  nearer 
to  the  corresponding  points  on  the  other  side.  Thus  the  conjugate 
diameters  become  lengthened  and  the  transverse  shortened  in  the 
middle  and  at  the  outlet  of  the  pelvis.  The  posterior  part  of  the 
acetabulum  is  pushed  more  backward,  and  thereby  the  spine  of  the 
ischium  is  turned  more  inward  than  would  be  the  result  of  mere 
inward  pressure  towards  the  median  line. 

The  tuberosities  once  brought  nearer  to  each  other  by  the  tilting 
of  the  innominate  bones  will  be  still  more  approximated  by  the  press- 
ure exercised  against  them  in  the  sitting  posture. 


480  ABNORMAL   LABOR. 

In  lumbosacral  kyphosis  the  sacrum  is  short  and  narrow,  and  there 
is  no  real  promontory. 

Diagnosis. — The  diagnosis  is  based  on  the  presence  of  the  kyphosis 
and  on  pelvimetry.  The  conjugate  of  the  outlet  is  found  by  measuring 
the  distance  from  the  upper  end  of  the  pubic  arch  to  the  outer  sur- 
face of  the  end  of  the  sacrum,  which  normally  is  about  5  inches  (12.3 
centimetres),  and  subtracting  |  inch  (1.5  centimetres).  If  there  is  an 
ankylosis  between  the  sacrum  and  the  coccyx,  it  is  the  distance  from 
the  apex  of  this  latter  bone  which  is  to  be  taken.  The  distance  from  one 
tuberosity  of  the  ischium  to  the  other  can  also  be  measured  directly. 

Prognosis. — The  prognosis  is  bad.  It  depends  chiefly  on  the  size 
of  the  outlet.  The  kyphotic  pelvis  is  often  combined  with  pendulous 
abdomen.  Frequently  the  abdominal  surface  of  the  foetus  is  turned 
forward,  which  probably  is  due  to  the  retort  shape  of  the  uterus  in 
the  pendulous  abdomen.  The  anterior  part  of  the  vertex  with  the 
large  fontanelle  is  apt  to  descend.  Even  face  presentations  are  com- 
paratively frequent  in  this  form  of  pelvis.  A  favorable  circumstance 
is  that  the  transverse  diameter  of  the  outlet  is  apt  to  become  a  little 
elongated  during  the  passage  of  the  child,  which  is  due  to  mobility  in 
the  sacro-iliac  articulation. 

Treatment. — If  the  patient  is  seen  during  pregnancy,  the  induction 
of  premature  labor  may  be  indicated.  Since  the  contraction  increases 
downward,  the  head  will  descend  some  and  then  stick.  If  the  trans- 
verse diameter  is  not  too  short,  the  accoucheur  may  be  able  to  pull 
the  head  through  with  the  forceps.  But  if  the  transverse  diameter  is 
less  than  3J  inches  (8  centimetres),  the  forceps  becomes  a  dangerous 
instrument.  The  vagina  may  be  torn,  articulations  ruptured,  or  the 
pelvic  bones  fractured.  Under  such  circumstances  it  is  better  to  per- 
forate or  to  resort  to  Caesarean  section  before  any  other  attempt  is 
made.  Symphyseotomy  has  also  been  tried,  but  is  less  reliable, 
since  it  is  hardly  possible  to  calculate  how  much  space  will  be  gained 
at  the  outlet. 

Rhachitic  Kyphotic  Pelvis. — As  we  have  seen,  the  common  cause 
of  a  kyphotic  pelvis  is  Pott's  disease,  tuberculosis  of  the  vertebrse. 
Much  more  rarely  the  kyphosis  is  due  to  rhachitis.  Since  the  rha- 
chitic pelvis  usually  has  a  form  that  is  almost  the  opposite  of  that  of 
the  kyphotic,  a  curious  mixture  results  when  the  two  are  combined. 
Nearly  all  the  characteristics  of  a  rhachitic  pelvis  are  lost,  except  that 
the  ilia  are  small  and  wide  open  in  front,  leaving  a  long  distance  be- 
tween their  anterior  superior  spines,  and  that  the  sacrum  is  flat  from 
side  to  side  instead  of  being  strongly  curved. 

If  the  kyphosis  is  situated  in  the  dorsal  region,  there  is  a  com- 
pensating lordosis  in  the  lumbar  region,  and  the  pelvis  becomes  a 
common  rhachitic  pelvis. 


DEFORMITIES   OF   THE    PELVIS. 


481 


Kyphoscoliotic  Rhachitic  Pelvis. — The  pelvis  becomes  still  more 
peculiar  if  to  the  kyphosis  is  added  scoliosis  in  a  rhachitic  person. 
This  combination  produces  a  more  or  less  pronounced  asymmetric 
pelvis.  On  the  side  of  the  scoliosis  the  inclination  of  the  pelvis  is 
small,  while  the  opposite  side  is  much  inclined.  At  the  outlet  the 
obliquity  is  generally  just  the  opposite  of  what  it  is  at  the  brim. 

Pelvis  Obtecta  (Fehling),  or  Spondylizema  (Herrgott). — When 
the  kyphosis  is  situated  between  the  sacrum  and  the  lumbar  vertebrae 
or  exclusively  in  the  sacrum,  the 

vertebral  column  may  be  so  much  ^^      '' 

bent  forward  as  to  cover  the  en- 
trance of  the  pelvis  (Fig.  367). 

In  consequence  of  osteitis,  gen- 
erally of  tuberculous  nature,  the 
bodies  of  the  vertebrae  affected 
become  rarefied  and  are  crushed 
together  by  the  weight  of  the  upper 
portion  of  the  body.  The  rem- 
nants of  the  vertebral  bodies  and 
the  arches  form  a  wedge  which 
enters  the  column  from  behind 
and  drives  it  forward.  From  an 
obstetric  stand-point  the  true  con- 
jugate becomes  then  the  shortest 
distance  from  the  symphysis  to  the  vertebral  column, 
has  been  found  reduced  to  1^  inches  (4  centimetres). 

The  women  who  have  such  a  pelvis  are  unable  to  stand  upright. 
Sometimes  they  may  obtain  their  equilibrium  by  bending  the  knees. 
If  they  stretch  the  lower  extremities,  they  are  obliged  to  seek  support 
for  their  bodies  on  canes,  which  they  carry  in  their  hands,  so  that 
they  virtually  are  reduced  to  quadrupeds. 

3.  Funnel-Shaped  Pelvis. — A  funnel-shaped  pelvis  (Fig.  368)  is  one 
that  is  comparatively  large  at  the  brim  and  narrow  at  the  outlet.  Most 
funnel-shaped  pelves  are  the  result  of  lumbosacral  kyphosis  and  have 
been  considered  above.  But  in  some  cases  a  similar  shape  is  found 
in  women  who  have  a  normal  spine.  The  contraction  is  generally 
moderate  in  degree  and  found  only  in  the  transverse  direction,  but 
it  may  extend  over  a  large  portion  of  the  pelvis,  and  if  there  is  an 
ankylosis  between  the  sacrum  and  the  coccyx  the  space  is  consid- 
erably diminished. 

Etiology. — In  England  this  form  of  pelvis  has  particularly  been 
met  with  among  society  ladies,  and  is  attributed  to  frequent  horseback 
riding  indulged  in  at  a  tender  age,  when  the  pelvis  is  still  pliable.  At 
all  events  it  is  probably  a  modification  of  an  infantile  pelvis. 

31 


Pelvis  obtecta      (Tarmer  and  Budm,  1  e  ) 


This  distance 


482  ABNORMAL   LABOR. 

Diagnosis. — The  funnel-shaped  pelvis  is  hardly  known  to  exist 
before  delivery.  Then  attention  is  called  to  it  by  the  head  sticking 
in  the  cavity  of  the  pelvis.  Exact  measurements  as  described  under 
kyphotic  pelvis  clear  up  the  diagnosis. 

Prognosis. — As  the  contraction  in  most  cases  is  of  moderate  degree, 
the  prognosis  in  general  is  not  bad.  Still,  infantile  mortality  is  much 
increased,  and  even  the  mother  is  exposed  to  considerable  danger. 
If  the  head  is  not  helped  out  in  time  the  soft  tissues  become  inflamed 
and  gangrenous,  and  the  result  may  be  a  vesicovaginal  fistula  or  a 
stricture  of  the  vagina,  or  even  the  bones  forming  the  pubic  arch  fall 
a  prey  to  caries.  If  the  distance  between  the  tuberosities  of  the  ischia 
is  less  than  3|  inches  (9  centimetres),  the  situation  is  grave. 

Treatment. — If  the  existence  of  a  funnel-shaped  pelvis  is  known 
or  recognized  during  pregnancy,  it  may  be  proper  to  avoid  trouble  by 

Fig.  368. 


Funnel-shaped  pelvis.     (Ahlfeld.) 

the  induction  of  premature  labor.  During  labor  a  prompt  recourse 
to  the  forceps  is  indicated,  but  if  the  impacted  head  does  not  soon 
yield  to  a  reasonable  amount  of  traction,  and  the  foetus  is  alive, 
symphyseotomy  is  likely  to  give  all  the  enlargement  needed  in  the 
transverse  direction.  Too  protracted  traction  may  lead  to  fracture  of 
the  pelvis,  rupture  of  its  articulations,  or  serious  tears  of  the  soft 
parts.  Caesarean  section  will  hardly  ever  deserve  consideration.  If 
the  foetus  is  dead,  craniotomy  or  cephalotripsy '  should  at  once  be 
performed  in  the  interest  of  the  mother. 

§  3.  Incurved  Pelvis. — In  the  incurved  pelvis  the  walls,  instead 
of  being  bent  outward,  are  curved  inward. 

To  this  class  belong,  1,  the  osteomalacic  pelvis  and,  2,  the  pseudo- 
osteomalacic  rhachitic  pelvis. 


DEFORMITIES    OF    THE    PELVIS.  483 

1.  The  Osteomalacic  Pelvis. — The  osteomalacic  pelvis  is  the  result 
of  a  disease  called  osteomalacia,  v^^hich  is  characterized  by  a  softening 
of  the  bones.  Unlike  rhachitis,  with  which  it  formerly  was  con- 
founded, it  is  a  disease  of  the  adult.  It  generally  makes  its  appear- 
ance when  the  patient  is  between  twenty-five  and  thirty-five  years  of 
age.  It  is  by  far  more  common  in  women,  but  is  also  found  in  men, 
and  is  most  frequently  connected  with  pregnancy,  the  puerperal  state, 
and  lactation.  It  is,  however,  found  also  in  nulliparous  women.  Some- 
times there  are  exacerbations  at  the  menstrual  periods,  but  the  disease 
may  make  its  first  appearance  after  the  menopause. 

The  calcareous  matter  in  the  bones  is  absorbed,  and  the  medullary 
substance  is  encroaching  upon  the  bone.     Two  forms  of  the  disease 

Fl-,.  369. 


Sagittal  section  of  an  osteomalacic  pelvis,  showing  disappearance  of  bony  tissue.    (Ahlfeld 


have  been  distinguished, — viz.,  osteomalacia  cerea,  or  waxy  osteomala- 
cia, and  osteomalacia  fragilis,  or  brittle  osteomalacia  ;  and  the  distinc- 
tion is,  as  we  shall  see,  of  importance  for  the  practical  obstetrician ; 
but  in  reality  it  is  only  a  question  of  degree  of  the  same  destruction. 
If  the  inner  portion  of  a  bone  is  affected  and  there  remains  a  thin 
bony  shell,  this  is  very  liable  to  break,  while  if  the  bone  is  softened  in 
its  whole  mass,  it  will  bend  and  be  flexible  as  wax. 

The  disease  usually  begins  in  the  pelvis  or  the  spine  (Fig.  369),  but 
it  may  gradually  implicate  most  of  the  skeleton  (Fig.  370). 

The  osteomalacic  pelvis  is  very  characteristic.  On  account  of  the 
disappearance  of  the  lime  salts  from  the  composition  of  the  bone,  it  is 
of  very  light  weight,  incurved,  and  often  fractured.  The  same  factors 
that  go  to  give  a  normal  pelvis  its  shape— the  superimposed  weight, 
the  pressure  of  the  femora  against  the  acetabula,  the  resistance  of  liga- 


484 


ABNORMAL   LABOR. 


merits,  and  the  traction  of  muscles — are  at  work  here,  but,  being  ex- 
ercised on  flexible  or  brittle  bones,  they  find  no  resistance,  and  the 
result  is  that  the  walls  of  the  pelvis  are  bent  or  crushed  inside  into 
the  cavity  (Figs.  371,372). 

The  promontory  is  pressed  forward  and  downward.  The  sacrum 
is  strongly  curved  longitudinally,  the  apex  being  turned  forward.  The 
acetabula  are  approximated,  the  ascending  branch  of  the  pubis  bent 
inward,  likewise  the  pillars  forming  the  pubic  arch,  so  that  the  sym- 
physis pubis  protrudes  forward  like  a  trunk.  The  tuberosities  of  the 
ilia  are  brought  nearer  to  each  other,  and  may  even  come  in  contact 

Fig.  370. 


Woman  affected  with  osteomalacia.     (From  an  engraving  in  the  MusiJe  Dupuytren  in  Paris.) 

with  each  other.  The  anterior  portion  of  the  ilium  is  turned  inward 
and  downward.  The  brim  of  the  pelvis  has  the  shape  of  the  letter  Y, 
the  sacrocotyloid  distance  and  the  transverse  diameter  being  much 
diminished.  There  is  also  some  asymmetry  in  the  pelvis.  The 
deformity  increases  in  the  course  of  time,  especially  in  consequence  of 
repeated  pregnancies.  It  may  become  so  great  that  a  marble  one  inch 
in  diameter  cannot  pass  through  the  pelvis.  Coition  may  become 
impossible  and  defecation  difficult. 

Osteomalacia  being  exceedingly  rare  in  this  country,  I  add  an  illus- 
tration of  a  specimen  in  Wood's  museum  (Fig.  373),  although  the 
deformity  is  less  pronounced. 

Symptoins. — In  the  begmning  the  disease  is  obscure.     The  first 


DEFORMITIES    OF    THE    PELVIS. 


485 


symptom  complained  of  is  pain  in  the  bones  of  the  pelvis  or  spine, 
which  pain  is  increased  by  pressure.  There  soon  appears  a  difficulty 
in  lifting  the  leg  or  abducting  it,  which  causes  a  stumbling  and  wad- 


FiG.  371. 


Osteomalacic  pelvis,  front  view.    (AhlfeM. 


dling  gait.  The  knee-jerk  is  increased.  There  is  tremor  of  the 
muscles.  Next  the  stature  is  shortened  and  bones  become  soft  and 
flexible  or  brittle.  Even  the  soft  tissues  may  become  friable,  several 
operators  having  reported  that  the  ligatures  cut  through  when  applied. 

Fig.  372. 


The  same  from  below. 


Etiology. — The  cause  of  the  disease  is  unknown,  and  there  is  great 
diversity  of  opinion  as  to  its  true  starting-point.  Some  look  upon  it 
as  an  osteomyelitis.      Others  go  still  further  back  and  suppose  that 


486 


ABNORMAL   LABOR. 


the  cells  of  the  spinal  marrow  are  first  affected.     Others,  again,  see 
the  cause  in  a  pathologic  metabolism. 

Osteomalacia  is  endemic  in  some  rather  limited  localities  in 
Europe. — the  borders  of  the  Rhine  near  Cologne,  and  again  near  its 
outlet  in  Flanders,  Schiitt  Island  in  the  Danube,  and  the  valley  of 
the  Po  in  northern  Italy.  In  America  it  is  exceedingly  rare.  A  low, 
damp  residence  seems  to  be  a  feature  of  importance  in  its  causa- 
tion. The  bones  have  been  searched  in  vain  with  the  modern  tests 
for  bacteria.  The  ovaries  seem  to  have  a  decided  influence  on  the 
production  of  the  disease.     Sometimes  they  were  found  in  a  hyaline 

Fig.  373. 


Osteomalacie  pelvis.     (Wood's  Museum,  Bellevue  Hospital,  No.  154.)    One-third  actual  size. 


condition,  but  in  other  cases  they  were  perfectly  normal.  Perhaps 
they,  like  other  glands,  have  an  internal  secretion  which  is  an 
important  link  in  the  chemistry  of  the  organism. 

It  has  been  found  experimentally  that  Avhen  the  ovaries  are 
removed  from  a  healthy  animal,  the  excretion  of  phosphates  in  the 
urine  is  much  diminished.  It  is  also  clinically  proved  that  oopho- 
rectomy and  the  administration  of  phosphorus  are  most  effective  in 
arresting  the  disease.  The  removal  of  the  ovaries  therefore  saves 
phosphorus,  and  they  are  suspected,  when  present,  of  causing  osteo- 
malacia by  too  great  oxidation  and  elimination  of  phosphorus.     It 


-      DEFORMITIES    OF    THE    PELVIS.  487 

must,  however,  be  remembered  that  the  disease  may  be  found  in  men. 
What  is  sure  is  that  pregnancy,  the  puerperal  state,  and  lactation 
have  a  decidedly  bad  influence  on  the  progress  of  the  disease,  but  it 
may  be  found  in  women  who  have  never  borne  a  child,  and  it  may 
begin  after  the  menopause. 

Poor  food  may  contribute  to  the  production  of  the  disease  by 
lowering  the  tone  of  the  whole  constitution,  but  does  not  in  itself 
cause  osteomalacia,  which,  on  one  hand,  may  attack  well-fed  persons, 
and,  on  the  other  hand,  is  nearly  unknown  in  Ireland  and  parts  of 
Russia  among  a  large  population  living  in  abject  poverty. 

Diagnosis. — In  the  beginning  osteomalacia  is  not  easily  recognized 
and  is  often  taken  for  rheumatism  or  spinal  disease.  A  point  of  diag- 
nostic importance  is  that  the  pain  is  seated  in  the  bones,  especially 
the  sacrum,  the  hip-bones,  the  vertebrae,  and  the  ribs,  and  is  increased 
by  pressure. 

Rickets  is  a  disease  of  early  childhood,  osteomalacia  appears  after 
the  skeleton  is  perfectly  ossified.  In  rickets  the  epiphyses  of  the 
bones  are  thickened,  while  in  osteomalacia  they  are  of  normal  dimen- 
sions. In  rickets  there  is  not  much  pain,  whereas  pain  is  a  chief 
symptom  in  osteomalacia.  In  rickets  the  lower  extremities  are  more 
distorted  than  any  other  part  of  the  body,  while  in  osteomalacia  they 
often  escape. 

The  increased  knee-jerk  and  the  impaired  power  of  bending  the 
legs  on  the  abdomen  and  of  abducting  them  help  to  diagnosticate  osteo- 
malacia at  an  early  date.  When  the  stature  diminishes  and  deformity 
sets  in,  the  diagnosis  is  easy.  As  to  the  pelvis,  it  is  a  point  of  great 
diagnostic  importance  that  the  woman  may  have  given  birth  to  chil- 
dren without  difficulty  before  the  beginning  of  the  disease  which  may 
distort  her  pelvis  to  such  an  extent  that  she  can  be  delivered  only  by 
Csesarean  section.  It  is  true,  carcinoma  of  the  bones  of  the  pelvis 
may  produce  a  similar  condition,  but  then  there  is  a  history  of  pre- 
vious carcinoma  in  some  other  portion  of  the  body. 

The  diagnosis  of  the  osteomalacic  pelvis  is  in  the  beginning  not 
always  easy,  and  can  only  be  made  with  the  half  or  whole  hand,  but 
later  the  type  is  easily  recognized.  From  the  lumbosacral  kyphotic 
pelvis  it  is  distinguished  by  the  well-defined  protruding  promontory, 
the  strong  curvature  of  the  sacrum,  the  inward  curvature  of  the 
ilium,  the  Y-shape  of  the  brim,  and  the  trunk-like  symphysis.  The 
promontory  may  be  so  low  that  the  common  iliac  arteries  are  felt 
pulsating,  which  has  been  given  as  a  sign  of  spondylolisthesis  ;  but 
then  the  whole  shape  of  the  pelvis  is  entirely  different  from  that  of  the 
spondylolisthetic  pelvis,  as  we  presently  shall  see. 

The  diagnosis  between  the  two  varieties,  osteomalacia  cerea  and 
osteomalacia  fragilis,   is   of  importance   in  regard  to   prognosis  and 


488  ABNORMAL   LABOR. 

treatment.  In  the  flexible  variety  it  is  often  possible,  without  causing 
much  pain,  to  separate  the  tuberosities  of  the  ischia  or  to  bend  the 
crest  of  the  ilium  back  towards  the  spine. 

Prognosis. — The  prognosis  is  much  better  now  than  it  was  twenty- 
five  years  ago.  We  know  that  the  disease  is  curable,  and  we  have 
gained  considerable  control  over  it  by  medical  and  surgical  means. 

In  regard  to  labor,  not  a  few  cases  .end  favorably  by  nature's  sole 
efforts.  Others  demand  more  or  less  dangerous  operations  or  may 
lead  to  death  by  rupture  of  the  uterus.  In  half  of  the  reported  cases 
the  patient  succumbed. 

Treatment. — Taking  into  consideration  the  gravity  of  labor  and  the 
unquestionably  bad  influence  of  pregnancy  and  the  puerperal  state, 
the  writer  takes  it  to  be  justifiable  to  provoke  abortion  if  the  case  is 
seen  so  early  that  the  foetus  can  be  easily  removed  by  the  natural 
way.  After  that  the  patient  should  occupy  a  dry,  sunny  house  and 
have  as  substantial  food  as  possible,  of  which  milk  should  form  a 
large  ingredient.  The  chief  remedial-  agent  is  phosphorus,  of  which 
gY,  ^L  to  yV  (3-4  milligrammes)  should  be  taken  three  times  a  day. 
Another  important  remedy  is  the  extract  of  red  bone  marrow,  a  table- 
spoonful  three  times  a  day.  Cod-liver  oil  is  also  said  to  have  effected 
a  cure.  Protracted  and  repeated  inhalation  of  chloroform  has  in 
some  cases  proved  very  effective,  while  in  others  it  has  been  useless. 
Frequent  tepid  baths  with  chloride  of  sodium  or  sulphur  may  be  used 
as  adjuvants.  They  relieve  pain  and  keep  the  skin  in  good  condition. 
It  need  hardly  be  added  that  pregnancy  should  be  avoided,  in  which 
respect  the  only  reliable  methods  are  abstinence  from  sexual  inter- 
course or  the  use  on  the  male  organ  of  a  rubber  protector. 

If,  in  spite  of  prophylaxis,  diet,  regimen,  and  drugs,  the  disease 
is  not  cured,  recourse  should  be  had  to  surgical  means.  The  ovaries 
should  be  removed,  and  perhaps  it  is  still  better  to  amputate  the 
uterus  at  the  same  time. 

If  the  patient  is  seen  late  in  pregnancy,  our  conduct  must  depend 
on  the  degree  of  deformity  present  and  the  variety  of  the  disease. 
If  there  is  only  slight  deformity,  and  if  the  disease  is  of  the  flexible 
variety,  perhaps  the  induction  of  premature  labor  may  be  indicated. 
In  the  higher  degrees  of  deformity  Csesarean  section  should  be  per- 
formed a  couple  of  weeks  before  the  normal  end  of  pregnancy. 

Finally,  if  the  case  comes  under  observation  after  labor  has  begun 
and  the  deformity  is  great,  Ctesarean  section  should  be  performed  at 
once.  If,  on  the  other  hand,  there  seems  to  be  room  for  the  child  to 
pass,  we  may  hope  that  the  bones  may  yield  some,  and  see  what 
nature  can  do.  If  necessary,  we  help  with  the  forceps  or  perforate 
and  extract  with  forceps  or  cranioclast. 

When  Csesarean  section  is  performed  the  ovaries  should  be  re- 


DEFORMITIES    OF    THE    PELVIS. 


489 


moved  so  as  to  prevent  future  impregnation  and  eliminate  the  delete- 
rious influence  of  these  glands  on  the  metabolism  ;  or  the  uterus  may 
be  amputated  at  the  internal  os  or  totally  extirpated.^ 

2.  PsEUDo-OsTEOMALAcic    Rhachitic    Pelvis. —  A    fomi    of   pelvis 
much  like  the  osteomalacic  may  be  produced  by  rhachitis,  and  is  then 

Fig.  374. 


Pseudo-osteomalacic  pelvis,  front  view.    (Clausius.) 

called  the  pseudo-osteomalacic  pelvis  (Figs.  374,  375).  The  brim  is 
triangular,  the  acetabula  are  pressed  inward,  the  symphysis  protrudes 
forward,  the  ascending  branch  of  the  pubis  is  bent  inward,  the  tuber- 
osities of  the  ischia  are  approximated  to  each  other,  and  the  pubic 
arch  is  narrow.     The  rhachitic  origin  is  shown  by  the  smallness  of 

Fig.  375 


Pseudo-osteomalacic  pelvis  seen  from  above.    (Clafisius.) 


the  bones,  especially  the  ilium,  their  flat  position,  and,  as  a  rule, 
their  anterior  gaping ;  but  sometimes  even  that  may  be  absent,  and  the 
anterior  part  of  the  ilium  may  be  turned  inward  as  in  osteomalacia. 
The  bones  of  the  pelvis  are  more  compact,  solid,  and  heavy.  The 
most  distinctive  point  is,  however,  to  be  found  in  Ihe  liistory,  rhachitis 

*  Garrigues,  Diseases  ofWomen,  third  cil.,  ji.  517. 


490 


ABNORMAL   LABOR. 


being  a  disease  of  childhood,  appearing  before  ossification  is  finished, 
and  osteomalacia  occurring  in  the  adult  and  consisting  in  the  emolli- 
tion  of  the  already  hardened  bone.  Exceptionally,  there  may,  how- 
ever, with  the  rhachitis,  be  an  osteoporosis,  a  reabsorption  of  already 
formed  bony  tissue ;  but  that  is  then  really  a  combination  of  osteo- 
malacia and  rhachitis. 

The  pseudo-osteomalacic  pelvis  is  produced  if  the  lower  extremi- 
ties are  much  used  at  a  time  when  the  pelvic  bones  are  very  soft  in 
consequence  of  rhachitis. 

It  is  a  very  rare  form  of  pelvis.  The  coarctation  may  be  quite 
considerable,  and  the  same  rules  apply- to  the  conduct  of  the  obstetri- 
cian as  in  osteomalacic  pelvis. 

§  4.  Spondylolisthetic  Pelvis. — The  word  spondylolisthesis  means 
sliding  of  a  vertebra.     A  spondylolisthetic  pelvis  (Fig.  376)  is  one  in 


Fig.  376. 


Si>ondylolisthetic  pelvis.    ( Olshausen-Veit. 


which  the  body  of  tlie  fifth  lumbar  vertebra  has  slid  forward  into  the 
upper  strait  and  the  cavity  of  the  pelvis,  where  it  leans  against  the 
anterior  surface  of  the  first  or  even  the  two  uppermost  sacral  vertebrae. 
The  spinous  process  stays  in  its  place  and  so  does  the  inferior  articu- 
lar process,  while  the  superior  goes  with  the  body.  This  is  only  pos- 
sible by  an  elongation  or  a  fracture  taking  place  in  the  arch  of  the 


DEFORMITIES   OF   THE    PELVIS.  491 

vertebra  (Figs.  377,  378).  As  a  rule,  this  is  a  slow  process,  due  to 
imperfect  ossification  and  the  carrying  of  heavy  weights,  but  a  similar 
condition  results  if  through  injury  the  vertebra  is  broken  suddenly, 
as  on  the  woman  whose  pelvis  is  seen  in  Fig.  78,  p.  108. 

When  the  vertebral  body  slides  down  in  front  of  the  sacrum,  the 
intervertebral  cartilage  atrophies  and  disappears,  the  bones  become 
smoothed  off  through  pressure  against  each  other,  and  sometimes 
they  grow  together,  when  further  sliding,  of  course,,  is  rendered  im- 
possible. Although  this  is  one  of  the  rarer  deformities,  a  considera- 
ble number  of  spondylolisthetic  pelves  have  of  late  years  been  observed 
and  descrilDed. 

The  displacement  of  the  vertebra  has  very  serious  consequences, 
both  in  regard  to  the  spinal  column  and  the  shape  of  the  pelvis.     By 

Fig.  378. 


Normal  lumbar  vertebra.  Lumbar  vertebra  with  elongated  interartieular 

portion.     (Xeugebauer. ) 

the  sliding  the  centre  of  gravity  is  brought  farther  forward.  In  order 
to  compensate  this  disturbance  the  trunk  bends  backward  and  the 
lumbar  portion  of  the  vertebral  column  forms  a  strong  convexity  for- 
Avard.  This  lordosis  obstructs  the  entrance  of  the  pelvis,  so  that' the 
nearest  point  to  the  symphysis  pubis  may  be  found  on  the  fourth,  the 
third,  and  even  the  second  lumbar  vertebra,  and  this  distance  measures 
only  between  2  and  3  inches  (5  and  8  centimetres). 

In  the  pelvis  great  changes  of  form  are  inaugurated.  By  the  press- 
ure exercised  by  the  vertebral  column  the  sacrum  is  tilted  around 
a  transverse  axis  so  that  the  upper  end  is  pushed  back  and  the  apex 
forward.  The  base  is  driven  backward,  and  must  as  a  wedge  sep- 
arate the  posterior  spines  of  the  ilia  from  each  other.  The  apex  is 
driven  in  the  direction  of  the  pubic  arch  aud  shortens  the  antero- 
posterior diameter  of  the  outlet.  The  upper  ends  of  the  hip-bones 
being  driven  farther  apart,  the  lower  ends  must  be  brought  nearer 
together.  Consequently  the  distance  between  the  tuberosities  of  the 
ischia  is  diminished.  The  outlet  is  then  diminished  l3oth  in  the 
anteroposterior  and  in  the  transverse  diameter. 

At  the  brim,  the  filth  lumbar  vertebra  lying  in  front  of  the  sacrum, 
the  conjugate  becomes  shortened,  while  through  tlie  spreading  apart 
of  the  hip-bones  t lie  transverse  diameter  becomes  somewhat  elongated. 


492 


ABNORMAL   LABOR. 


When  the  Aveight  of  the  trunk  is  brought  forward,  a  compensatory 
movement  takes  place  in  the  pelvis.  It  is  lifted  in  front  and  tilted 
backward  around  a  transverse  axis.  In  this  way  the  inclination  of 
the  pelvis  becomes  much  diminished.  But  thereby  the  iliofemoral 
ligament  becomes  stretched,  and  that  again  pushes  the  femora  against 
the  acetabula  and  contributes  to  the  approximation  to  each  other  of 
the  tuberosities  of  the  ischia. 

Etiology. — As  a  rule,  there  is  a  congenital  predisposition.  But 
perhaps  even  the  carrying  of  great  weights  can  force  a  normal  ver- 
tebra out  of  its  connection  with  the  adjacent  bones.  In  many  cases 
the  displacement  is  due  to  injury,  especially  in  youth. 


Fig.  379. 


Fig.  380. 


Fig.  381. 


Aspect  of  a  patient  with  a  spondylolisthetic  pelvis.     (Ahlfeld.) 


Diagnosis. — The  diagnosis  is  not  difficult.  Often  the  mere  aspect 
of  the  patient  suffices  to  make  it  (Figs.  379,  380,  381).  The  thorax 
and  legs  are  normal,  but  there  is  a  remarkable  shortening  of  the 
abdomen,  the  upper  part  of  the  wall  sinking  into  the  pelvis  and  the 
lower  hanging  forward  over  the  symphysis.  On  account  of  the  slight 
inclination  of  the  pelvis  the  mons  Veneris  and  the  vulva  are  brought 
more  upward  and  forward.  The  skin  being  too  large,  two  wide  folds 
form  over  the  crests  of  the  ilia.  The  hips  are  far  apart.  The  loins 
are  deeply  pressed  forward,  and  the  sacrum  is  felt  protruding  back- 
ward. 


DEFORMITIES    OF   THE    PELVIS. 


49r 


By  vaginal  examination  the  obstetrician  feels  the  displaced  vertebra 
in  front  of  the  sacrum.  On  account  of  the  small  inclination  of  the  pel- 
vis the  common  iliac  arteries  or  even  the  end  of  the  abdominal  aorta 
may  be  felt,  but  that  may  also  be  the  case  in  lumbosacral  kyphosis. 

A  low  degree  of  pelvic  inclination,  which  constitutes  such  a 
prominent  feature  of  the  spondylolisthetic  pelvis,  is  also  found  in 
lumbosacral  kyphosis,  in  osteomalacia,  and  in  rhachitis,  but  there  are 
distinctive  features  of  each  of  these  conditions.  None  of  them  pro- 
duces the  peculiar  shape  of  the  abdomen  just  described. 

In  kyphosis  there  is  the  external  gibbosity.  There  is  no  hollow 
back.  The  false  pelvis  is  large ;  the  promontory  is  little  marked,  or 
cannot  be  reached  at  all.     The  alae  of  the  sacrum  cannot  be  reached. 

The  osteomalacic  pelvis  has  the  protruding  symphysis,  the  narrow 
pubic  arch,  and  the  Y-shaped  brim.  The  sacrum  is  strongly  curved 
longitudinally.     The  ilia  are  curved  inward  in  their  anterior  portion. 

As  to  rhachitis,  it  may  be  difficult  to  decide  whether  the  hollow 
felt  under  the  promontory  is  due  to  the  curvature  of  the  sacrum  itself, 
as  in  rhachitis,  or  to  the  displacement  of  the  lumbar  vertebrae  in  re- 
gard to  the  sacrum,  which  characterizes  spondylolisthesis.  But  first 
of  all,  we  have  the  history  of  rhachitis  in  childhood.  Next,  we  observe 
characteristic  pathological  changes  in  the  skeleton, — curved  legs,  thick 
wrists,  chicken-breast,  etc.  Finally,  by  following  the  linea  terminalis 
from  the  promontory,  we  feel  the  alae  of  the  sacrum  form  a  direct 
continuation  of  it,  while  in  spondylolisthesis  we  feel  only  the  dis- 
placed vertebra,  and  beyond  it  the  alae  of  the  sacrum,  but  not  as  a 
continuation. 

Prognosis. — The  prognosis  of  spondylolisthesis  is  bad.  The  nar- 
rowness extends  over  a  large  area,  and  may  be  very  considerable. 
Coarctation  may  begin  high  up  in  the  abdomen.  Great  resistance  is 
met  at  the  brim,  and  the  outlet  is 
considerably  contracted  in  both  di- 
rections. 

Treatment.  — Artifi  cial  ab  or  tio  n , 
induction  of  premature  labor,  or 
Caesarean  section  will  be  indicated 
in  most  cases.  The  obstetrician 
must  calculate  the  length  of  the 
substituted  true  conjugate,  and,  on 
account  of  the  extension  of  the  nar- 
row portion,  demand  half  an  inch 
(one  centimetre)  more  than  he  would  in  a  flat  pelvis  before  allowing 
labor  to  be  established. 

§  5.   Pelvis  Contracted  by  Tumors  springing  from  the  Pelvic 
Bones. — Large  tumors  attached  to  the  interior  walls  of  the  pelvis 


Fig.  382. 


Osteoma  of  sacrum.     (Olslmusoii-Veit.) 


494 


ABNORMAL    LABOR. 


may  practically  obliterate  it  from  an  obstetric  stand-point.  In  Fig. 
382  is  represented  an  osteoma  of  tlie  sacrum,  in  Fig.  383  an  en- 
chondroma  of  the  same.  In  other  cases  the  tumor  was  fibrous, 
sarcomatous,  or  carcinomatous. 

These  occurrences  are  exceedingly  rare,  and  each  such  case  must 
be  judged  on  its  own  merits,  but,  as  a  rule,  Cesarean  section  is  the 
only  available  method  of  delivery. 

Fig.  383. 


''"''^an..^! 


Enchondroma  of  sacrum.     (Stadfeldt.) 


§  6.  Split  Pelvis. — The  pelvic  ring  may  be  open  at  the  site  of  the 
symphysis  pubis  or  at  that  of  the  sacrum. 

1.  Pelvis  Split  at  Symphysis  Pubis. — In  early  fetal  life  the  pedicle 
of  the  allantois,  which  forms  the  bladder,  may  be  over-distended  with 
fluid  and  rupture.  In  consequence  of  this  the  bladder  remains  open 
in  front — so-called  exstrophy  of  the  bladder — and  the  symphysis  is  only 
formed  by  strong  ligaments,  which  admit  movements  of  the  ends  of 
the  pubic  bones. 

Most  of  such  children  are  stillborn  or  die  early  in  life.  Those 
who  survive  have  a  constant  dripping  of  urine  from  the  exposed  ends 
of  the  ureters,  and  are  not  very  likely  to  become  impregnated. 


DEFORMITIES   OF   THE    PELVIS. 


49; 


The  pelvis  with  split  symphysis  (Fig-.  384)  makes  the  impression 
of  being  somewhat  flat,  which  must  be  due  to  the  resistance  offered 
by  the  strong  ligaments  uniting  the  bones  in  front. 


Fm.  384. 


Pelvis  without  symphysis  pubis.     (Ahlfeld.) 

In  the  few  cases  of  labor  in  a  pelvis  with  split  symphysis  that 
have  been  reported,  artificial  help  was  needed  on  account  of  inability 
of  using  the  abdominal  pressure  or  a  faulty  presentation  of  the  foetus. 

Fig.  385. 

4M^ 


Pelvis  without  sacrum.     (Litzmanu.) 


In  several  a  very  narrow  vaginal  entrance  necessitated  deep  incisions. 
In  one  case  symphyseotomy  was  performed  by  cutting  the  ligaments 
replacing  the  symphysis.     One  woman  was  delivered  with  the  forceps. 


496  ABNORMAL   LABOR. 

2.  Pelvis  Split  at  Sacrum. — The  posterior  breach  in  the  pelvic 
ring  is  produced  by  deficient  development  of  the  sacrum  (Fig.  385)  or 
by  surgical  removal  of  the  bone. 

The  few  specimens  known  in  which  the  sacrum  was  rudimentary 
were  of  the  infantile  type.  One  case  occurred  after  extirpation  of  the 
sacrum.  The  mechanism  of  labor  w^as  normal,  and  a  large  child  was 
born  without  difficulty. 

§  7.  Too  "Wide  Pelvis. — After  having  dwelt  so  long  on  pelves 
that  are  too  small,  it  is  quite  a  relief  to  come  to  one  that  is  too  wide. 
But  the  old  rule,  ne  quid  nimis,  holds  good.  Too  great  dimensions  of 
the  pelvis  may  as  well  become  a  source  of  dystocia  as  too  small  ones. 
In  the  first  place,  too  wide  a  pelvis  favors  precipitate  labor,  with  all 
its  dangers  to  mother  and  child, — hemorrhage,  laceration,  or  syncope, 
avulsion  of  the  umbilical  cord,  injury  to  the  child's  head,  etc.  (see 
pp.  359,  360).  Secondly,  too  much  space  interferes  with  the  normal 
mechanism  of  labor,  and  may  become  the  cause  of  faulty  positions 
that  demand  operative  interference.  Thus,  occipitoposterior  and 
occipitolateral  positions  (p.  362  et  seq.)  are  frequent  accompaniments 
of  the  too  wide  pelvis. 


CHAPTER   X. 
HEMORRHAGE. 


Some  loss  of  blood  is  normal  in  childbirth,  but  if  it  passes  certain 
limits,  it  is  one  of  the  most  serious  complications,  and  so  much  more 
terrific  as  the  hemorrhage  may  be  so  profuse  that  the  patient  succumbs 
almost  without  warning.  The  obstetrician  should  therefore  give  this 
subject  his  undivided  attention  and  prepare  himself  to  meet  this 
dangerous  and  insidious  foe. 

Hemorrhage  may  occur  during  pregnancy,  during  labor,  or  after 
labor.     We  have  spoken  of  it  in  connection  with  abortion  (p.  263). 

Towards  the  end  of  pregnancy  it  is  called  ante-partum  hemorrhage, 
and  after  the  birth  of  the  child  it  is  known  as  post-partum  hemorrhage. 
It  may  be  due  to  a  faulty  implantation  of  the  placenta, — placenta prcevia, 
— to  detachment  of  a  placenta  normally  inserted,  to  rupture  of  the 
circular  vein  of  the  placenta,  to  atony  of  the  uterus  or  inversion  of 
this  organ,  or  to  laceration  of  the  soft  parts  of  the  genital  canal. 

§  1.  Placenta  Praevia. — Placenta  prseviais  the  implantation  of  the 
placenta  at  the  internal  os.  It  may  be  divided  into  complete,  or  central, 
placenta  prsevia  and  incomplete,  of  partial,  which  again  is  subdivided 
into  marginal  placenta  praevia  and  lateral  placenta  prsevia.  It  is  called 
central  when  it  covers  the  whole  internal  os  (Fig.  386)  ;  marginal  if  it 
only  touches  a  part  of  the  margin  of  the  os,  and  lateral  if  it  does  not 


HEMORRHAGE. 


497 


reach  the  internal  os  at  all,  the  lowest  limit  of  it  being  somewhere  on 
the  lower  uterine  segment. 

Pathological  Anatomy. — Frequently  the  placenta  praevia,  besides 
being  abnormally  inserted,  is  abnormal  in  shape  and  construction. 
Often  it  is  membranous,  horseshoe-shaped,  or  accompanied  by  pla- 
centae succenturiatae.    On  the  atrophic  portions  of  the  placenta  the  villi 

Fig.  386. 


Central  placenta  praevia.  Half  actual  size.  From  a  patient  under  the  author's  care.  End  of 
sixth  month  of  pregnancy.  Entire  unruptured  ovum  expelled  after  tamponade  continued  for  three 
days.  No  loss  of  blood.  The  placenta  covers  the  whole  back  of  the  .specimen  and  a  little  of  the 
upper  end,  beside  the  whole  lower  end  and  nearly  half  of  the  front.  Most  of  the  phicenta  was 
inserted  on  the  anterior  surface  of  the  uterus.  The  shortest  distance  from  the  os  internum  to  the 
circumference  of  the  placenta  was  two  inches. 


of  the  chorion  are  covered  only  with  connective  tissue  and  not  with 
decidua.  Their  interior  is  full  of  granules  and  fat  drops  and  often  it 
is  the  seat  of  thrombosis.  This  imperfect  development  of  the  placenta 
is  probably  due  to  the  thinness  of  the  decidua  near  the  os  internum 
compared  with  that  higher  up  on  the  walls  and  the  fundus. 

Etiology. — Much  ingenuity  has  been  expended,  and  in  the  writer's 
opinion  wasted,  in  explaining  the  occurrence  of  placenta  praevia.     A 

32 


498  ABNORMAL    LABOR. 

chief  theory  is  that  the  faulty  insertion  is  due  to  an  arrested  abortion. 
The  advocates  of  this  theory  think  that  the  ovum  originally  is  embedded 
higher  up  in  the  uterus  and  becomes  detached  and  re-embedded  over 
or  near  the  os  internum.  But  if  we  take  into  consideration  that  the 
whole  unimpregnated  uterine  cavity  is  only  2^  inches  (6.5  centimetres) 
deep,  of  which  fully  one-half  belongs  to  the  cervix,  it  seems  to  me 
easy  to  imagine  that  the  ovum  may  not  as  usual  become  embedded 
at  a  short  distance  below  the  uterine  ostium  of  the  Fallopian  tube 
and  grow  downward,  chiefly  spreading  over  the  anterior  or  posterior 
wall,  but  is  carried  down  by  the  movement  of  the  cilia  of  the  uterine 
epithelium  and  even  by  gravity,  until  it  is  so  low  that,  when  it  grows, 
it  extends  to  or  even  beyond  the  internal  os.  This  theory  of  the 
primary  low  implantation  of  the  ovum  is  corroborated  by  the  clinical 
facts  that  placenta  prsevia  becomes  more  and  more  common  with 
repeated  pregnancies  and  that  uterine  catarrh  predisposes  to  it.  By 
repeated  pregnancies  and  endometritis  the  endometrium  becomes 
abnormal.  There  is  not  the  same  perfect  nidation,  prepared  to  catch 
the  ovum,  retain  it,  and  enclose  it.  It  slides  down  on  the  hardened, 
glazed  surface  of  the  uterus. 

In  many  cases  it  is  doubtless  lost,  being  washed  out  with  uterine 
secretions.  That  is  why  women  rarely  have  more  than  four  or  five  chil- 
dren, and  why  those  who  suffer  from  corporeal  leucorrhoea  rarely  be- 
come impregnated.  In  other  cases  the  ovum  is  arrested  and  finds  a 
seat  for  development  near  the  internal  os.  From  this  point  it  spreads 
upward  and  around  the  internal  os,  forming  the  horseshoe-shaped 
placenta  ;  or  it  may  extend  across  to  the  other  side,  as  shown  in  the 
figure.  In  this  case  nidation  probably  had  taken  place  on  the  pos- 
terior wall,  to  which  the  larger  and  thicker  part  of  the  placenta  was 
found  attached. 

In  exceptional  cases  the  placenta  may  even  extend  into  or  through 
the  cervix  by  tongue-shaped  prolongations,  reaching  as  far  as  the 
vaginal  surface  of  the  vaginal  portion ;  or  the  whole  cervix  may  be 
the  seat  of  the  placenta,  as  in  Fig.  387.  The  cervix  then  becomes 
unusually  thick  and  succulent,  and  the  decidua  is  formed  all  the 
way  down  to  the  external  os.  In  such  cases  I  think  the  original  im- 
plantation of  the  ovum  occurred  just  at  the  internal  os,  but  the 
growth  extended  only  in  the  direction  of  the  cervix  (cervical  placenta 
prcevia). 

Symptoms  and  Diagnosis. — The  chief  symptom  of  placenta  praevia 
is  the  hemorrhage.  Any  hemorrhage  occurring  in  the  latter  half  of 
pregnancy  must  awaken  the  suspicion  of  placenta  prtevia.  Generally, 
it  is,  however,  only  during  the  last  three  calendar  months  that  bleed- 
ing begins,  most  commonly  between  the  twenty-eighth  and  the  thirty- 
sixth  week,  less  frequently  between  the  thirty-seventh  and  the  fortieth 


HEMORRHAGE. 


499 


week,  and  still  less  frequently  at  the  normal  end  of  pregnancy.    Often 
pregnancy  ends  in  abortion  or  premature  labor. 

Placenta  prsevia  is  met  with  once  in  about  573  labor  cases.  The 
hemorrhage  comes  on  suddenly,  often  without  known  cause.  In  gen- 
eral the  causes  of  it  are  the  same  as  those  which  lead  to  hemorrhage 
from  a  normally  implanted  placenta,  such  as  the  rupture  of  a  uteropla- 
cental vessel  at  the  internal  os,  rupture  of  the  marginal  sinus  of  the 
placenta,  partial  separation  of  the  placenta  from  the  uterine  wall  in  con- 
sequence of  jerks  and  falls  or  uterine  contractions  which,  as  we  know, 
begin  early  in  uterogestation  (pp.  99  and  102).     In  many  cases  hemor- 

FiG.  387. 


Cervical  placenta  prsevia.     (Von  Weiss.) 


rhage  occurs  only  during  labor  or  after  the  birth  of  the  child.  In  rare 
cases  nature  itself  conquers  the  dangers.  The  bag  of  waters  is  rup- 
tured, the  presenting  part  compresses  the  bleeding  surface,  acting  like 
a  tampon.  Good  labor-pains,  causing  a  rapid  delivery,  favor  this  for- 
tunate termination.  But  this  event  is  so  rare  that  it  would  be  folly 
to  expect  it  and  await  it.  As  a  rule,  the  hemorrhage  is  so  great  that 
the  patient  deprived  of  the  help  of  obstetric  art  loses  her  life.  The 
hemorrhage  that  occurs  during  pregnancy  may  be  quite  moderate,  but 
there  is  no  telling  when  it  will  be  repeated  and  with  what  strength  it 
will  reappear.  A  patient  with  placenta  pmevia  is  in  constant  danger 
of  death.     Often  the  hemorrhages  occur  at  the  time  when  menstru- 


500  ABNORMAL    LABOR. 

ation  would  be  due,  doubtless  on  account  of  an  active  congestion 
taking  place  at  those  periods.  The  central  form  causes  the  worst 
hemorrhage.  As  a  rule,  the  cervix  and  lower  uterine  segment  are 
soft  and  yielding.  The  uterine  expansion  that  occurs  during  the  end 
of  pregnancy  may  therefore  take  place  without  causing  any  hemor- 
rhage, but  when  the  internal  os  begins  to  open  up,  the  lower  pole  of 
the  ovum  must  of  necessity  separate  from  the  uterine  wall,  and  this 
cannot  be  done  without  tearing  villi  of  the  chorion,  opening  uterine 
sinuses,  and  sometimes  tearing  uterine  arteries.  If  the  hemorrhage 
begins  after  delivery,  it  is  particularly  dangerous.  It  is  then  due  to 
atony  of  the  placental  site ;  and  the  best  natural  means  of  arresting 
uterine  hemorrhage,  muscular  contraction,  is  deficient  or  absent. 

The  blood  appears  externally  at  the  os  uteri  during  contractions, 
and  the  contractions  may,  of  course,  sever  vessels,  and  thus  cause 
bleeding ;  but,  on  the  other  hand,  contraction  compresses  torn  vessels 
and  prevents  them  from  bleeding,  and  pushes  the  presenting  part 
against  the  bleeding  surface  of  the  uterus,  which  it  compresses  like  a 
tampon. 

It  has  been  noticed  that  if  the  placenta  is  expelled  before  the  child, 
all  bleeding  ceases,  which  is  due  to  this  same  mechanism  of  uterine 
contraction  and  pressure  against  the  bleeding  surface  of  the  uterus. 

By  vaginal  examination  the  upper  part  of  the  vagina  or  one  side 
of  it  presents  a  peculiar  boggy  sensation,  due  to  the  presence  of  the 
placenta  in  that  locality. 

If  the  cervical  canal  is  open,  a  spongy,  soft  mass  is  felt,  which  can 
be  distinguished  from  a  mere  blood-clot  by  not  breaking  down  under 
pressure  with  the  examining  fmger.  The  wall  of  the  uterine  cavity 
may  be  divided  by  two  horizontal  lines  into  three  zones,  the  fundal 
zone,  the  middle  zone,  and  the  lower  zone,  composed  of  the  cervical 
canal  and  the  lower  uterine  segment.  The  fundal  zone  is  the  portion  of 
the  cavity  situated  above  the  uterine  apertures  of  the  Fallopian  tubes. 
This  is  often,  but  erroneously,  described  as  the  normal  seat  of  the 
placenta.  It  is  true,  the  placenta  may  extend  more  or  less  over  the  fun- 
dus, but  the  bulk  of  it  is  inserted  on  the  anterior  or  the  posterior  wall. 
The  middle  zone  corresponds  to  most  of  the  corpus  of  the  uterus  and 
extends  down  towards  the  line  that  marks  the  degree  of  dilatation  of 
the  external  os  necessary  to  let  the  head  pass.  To  this  extent  the 
uterus  must  retract  from  the  lower  pole  of  the  ovum,  and  if  any 
part  of  the  placenta  is  implanted  here  it  must  become  detached  from 
the  uterine  wall  as  far  as  this  line.  By  marking  the  largest  circum- 
ference of  the  fetal  head  and  measuring  the  distance  of  this  ring  from 
the  lowest  point  of  the  presenting  head,  we  find  that  the  distance  from 
the  external  os  to  the  ring  of  greatest  dilatation  is  about  3  inches  (8 
centimetres).     On  the  fundus  and  in  the  middle  zone  the  placenta  is 


HEMORRHAGE. 


501 


entirely  safe,  biit  in  the  lower  uterine  segment  it  must  be  detached 
when  labor  opens  up  the  internal  os,  and  hemorrhage  will  follow. 

The  uterine  contractions  are  often  weak,  and  not  infrequently  the 
placenta  is  adherent  and  must  be  removed  artificially. 

Prognosis. — Placenta  prpevia  is  one  of  the  gravest  complications 
of  labor.  It  is  fraught  with  danger  both  for  mother  and  child.  For 
the  mother  the  danger  consists  partly  in  loss  of  blood  and  partly 
in  the  exposure  to  infection  by  the 
manipulations  necessary  for  the  proper 
treatment  of  the  case.  The  child's  life 
is  also  endangered  by  loss  of  blood 
through  the  detached  part  of  the  pla- 
centa, but  especially  by  interference 
with  oxygenation  of  the  blood,  if  a 
large  portion  of  the  placenta  is  de- 
tached. If  the  whole  placenta  is  de- 
tached and  expelled  before  the  foetus, 
it  must  of  necessity  die,  unless  it  can 
be  delivered  from  its  prison  in  a  very 
short  time.  Many  children  die  on 
account  of  their  lack  of  maturity. 
Formerly  about  half  of  the  children 
succumbed.  As  to  the  mothers,  the 
mortality  used  to  be  twenty-five  or 
even  thirty-three  per  cent.,  but  by 
improved  methods  of  treatment  this 
has  been  brought  down  to  a  small 
percentage.  Hofmeier  lost  only  1  in 
46  mothers,  and  in  Pinard's  clinic 
infantile  mortality  has  been  reduced 
to  6.8  per  cent. 

Treatment — The  dangers  threatening  the  mother  and  the  foetus 
are  so  great  that,  as  a  general  rule,  we  may  say  that  the  latter's  life 
should  not  be  considered,  but  everything  done  to  save  the  former, 
unless,  of  course,  we  can  save  both.  Still,  if  the  foetus  has  not  reached 
the  age  of  viability,  we  may  try  to  continue  pregnancy  until  this  term 
is  reached.  If  hemorrhage  occurs  before  the  end  of  the  seventh  month, 
the  accoucheur  should  try  the  effect  of  absolute  rest  in  bed,  rectal  sup- 
positories containing  pulvis  opii  gr.  i  (6  centigrammes),  one  every  three 
hours,  fluid  extract  of  viburnum  prunifolium,  si,  internally  every  three 
hours,  adrenalin,  stypticin,  and  vaginal  suppositories  with  tannic  acid : 

R    Acid,  tannici,   ^i  ; 

01.  theobromae,   ,^ii. 
M.  et  ft.  suppositoria  No.  xii. 


Placenta  descending  to  boundary-line 
of  largest  expansion  of  the  external  os. 
(R.  Barnes.)  The  placenta  is  above  the 
line  and  therefore  safe.  The  space  between 
A  A  and  B  B  is  the  range  of  orificial  expan- 
sion necessary  to  permit  the  passage  of  the 
head. 


502  ABNORMAL    LABOR. 

The  diet  should  be  cool  and  bland,  and  the  bowels  should  be  kept 
open  with  a  sahne  aperient. 

If  the  child  is  dead,  it  is  also  best  to  follow  a  similar  course,  as 
the  placenta  will  atrophy,  and  the  danger  of  bleeding  during  and  after 
labor  will  be  much  lessened. 

If  the  hemorrhage  occurs  after  the  child  is  viable,  no  attempt 
should  be  made  to  prolong  pregnancy.  The  accoucheur  should  be 
guided  by  two  purposes, — to  stop  the  hemorrhage  and  to  avoid  injur- 
ing the  mother.  In  most  cases  the  cervix  is  soft  and  dilatable,  but  in 
others  it  is  friable  and  tears  easily.  The  mother's  condition  may  be 
so  low  in  consequence  of  loss  of  blood  sustained  before  the  arrival 
of  the  obstetrician  that  the  first  indication  is  to  gain  a  little  time  and 
allow  her  to  recuperate  before  beginning  any  operative  manipulations. 
Under  such  circumstances,  and  if  at  the  same  time  the  os  and  the 
cervical  canal  are  closed,  the  proper  thing  to  do  is  to  pack  the  vagina 
and  vulva  very  tightly  with  creolin  cotton  (see  Operations)  and  cover 
the  genitals  with  two  towels  rolled  so  as  to  form  hard  cylinders  and 
retained  in  place  by  a  T-bandage  with  two  tails  crossed  in  front  of 
the  towels.  For  safety's  sake  the  patient  should,  however,  be  watched 
all  the  time  with  regard  to  internal  hemorrhage  or  blood  soaking 
through  the  tampon.  Concealed  hemorrhage  would  betray  itself  by 
weakening  of  the  pulse,  pallor,  yawning,  and  clamminess  of  the  skin. 
If  the  tampon  works  well,  it  may  be  left  in  two  or  three  hours,  and, 
if  necessary,  renewed. 

But  if  the  patient's  condition  warrants  it,  and  the  cervix  is 
dilatable,  it  is  much  better  to  abstain  from  the  tamponade  and  begin 
artificial  dilatation  at  once  either  by  Harris's  or  Bonnaire's  method. 
(See  Operations.)  If  by  this  means  the  os  externum  can  be  dilated 
enough  to  pass  one  finger  through  the  cervical  canal,  the  placenta 
should  be  detached  from  the  lower  uterine  segment  as  far  as  the 
fmger  can  reach.  By  this  method,  first  recommended  by  Robert 
Barnes,  often  all  hemorrhage  stops,  and  it  will  do  so  still  more  surely 
when  the  operation  is  repeated  with  two  fingers,  because  this  will 
detach  the  placenta  from  the  whole  lower  uterine  zone  described 
above.  If  there  is  only  room  for  one.  finger  and  the  cervix  does  not 
readily  yield,  the  smallest  Barnes  bag  (see  Operations)  can  be  intro- 
duced, and  when  fully  dilated  replaced  by  the  second  size. 

As  soon  as  two  fingers  can  be  inserted,  the  foetus  should  be  turned 
and  one  foot  brought  down,  by  Braxton  Hicks's  method,  which  was 
particularly  invented  to  combat  placenta  praevia,  and  Avhich  will  be 
described  in  detail  in  speaking  of  obstetrical  operations.  When  one 
leg  is  brought  down  and  most  of  the  liquor  amnii  has  escaped,  the 
thigh  and  the  breech  serve  as  a  tampon  compressing  the  surface  of 
the  uterus  from  which  the  placenta  has  been  peeled  off. 


HEMORRHAGE.  503 

If  it  is  a  case  of  marginal  or  lateral  placenta  prrevia,  there  is  no 
difficulty  in  seizing  the  leg.  If  only  a  small  part  of  the  placenta 
covers  the  whole  os,  it  may  be  possible  to  get  at  the  membranes 
where  the  smallest  flap  is  situated.  But  if  the  whole  space  as  far 
as  the  obstetrician  can  reach  is  covered  with  placenta,  the  operator 
should  lose  no  time  in  perforating  it.  This  may  be  done  with  a 
long,  curved  artery-forceps  or  any  other  suitable  blunt  instrument, 
and  the  opening  thus  made  dilated  with  the  fingers. 

Some  recommend  puncturing  of  the  membranes  or  perforation 
of  the  placenta  as  soon  as  the  uterus  can  be  entered,  as  then  the  pre- 
senting part  sinks  down  and  presses  against  the  bleeding  surface;  but 
it  facilitates  the  podalic  version  to  have  unruptured  membranes. 

Thougli  turning  should  be  performed  as  early  as  it  can  be  done 
without  injuring  the  mother,  extraction  should  not  follow.  When 
hemorrhage  is  under  control  by  the  compression  exercised  by  the 
foetus,  we  should  give  the  cervix  all  the  time  needed  for  complete 
dilatation,  which  in  Hofmeier's  wonderfully  successful  series,  alluded 
to  above,  proved  to  be  from  one-half  hour  to  one  and  three-quarters 
hours.  During  this  time  it  is  well  to  give  hypodermic  injections  of 
large  doses  of  ergotine — as  much  as  6  grains  (40  centigrammes) — or, 
probably  better,  to  give  by  the  mouth  solution  of  adrenalin  chloride 
or  suprarenal  liquid  with  chloretone,  n\y  to  xxx,  or  stypticin  (gr. 
^  to  1 — from  3  to  6  centigrammes).  (See  below  under  Post-partum 
Hemorrhage.) 

In  order  to  avoid  the  danger  of  air  embolism,  it  is  safer  to  do  all 
manipulation  with  the  patient  in  the  dorsal  position.  When  the 
uterus  is  empty,  it  should  be  irrigated  with  creoline  emulsion  (1  per 
cent.). 

While  Braxton  Hicks's  method  did  so  much  for  the  mother,  it 
practically  ignored  the  foetus.  A  new  era  has  therefore  begun  by  the 
use  of  Champetier  de  Ribes's  unyielding  bag  and  the  substitution  of 
forceps  delivery  for  version.  (See  Operations.)  The  membranes  are 
not  only  ruptured,  but  torn  to  the  greatest  possible  extent.  If  neces- 
sary, the  placenta  is  also  perforated  and  torn.  Then  the  bag  is 
introduced  through  the  rent  and  filled  with  fluid.  By  direct  pressure 
on  the  bleeding  surface  of  the  uterus  it  arrests  hemorrhage.  By  pull- 
ing on  it  or  by  attaching  weights  to  it  by  means  of  a  rope  going 
over  a  pulley  at  the  foot  of  the  bed,  the  pressure  is  kept  up  and 
dilatation  of  the  cervix  is  accomplished.  When  the  fully  expanded 
bag  passes,  there  is  also  room  for  the  head  and  the  forceps. 

If  there  is  any  bleeding  after  delivery,  the  uterus  and  the  vagina 
should  be  tamponed,  the  first  with  sterile  gauze  or  iodoform  gauze, 
the  second  with  creoline  cotton.  Some  of  the  topmost  tampons 
might  also  be  wrung  out  of  chloride  of  iron  solution  (1  part  of  liquor 


504  ABNORMAL  LABOR. 

ferri  chloridi  to  10  parts  of  water),  which  has  still  higher  haemo- 
static power. 

If  much  blood  has  been  lost,  the  anaemic  condition  of  the  patient 
demands  attention  during  or  after  labor.  If  there  is  not  fluid  enough 
circulating  through  the  heart,  this  organ  gets  out  of  order  and  the 
patient  may  die  of  heart  failure.  The  chief  indication  is,  therefore,  to 
increase  the  amount  of  blood  circulating  through  the  body  by  means 
of  injection  of  normal  salt  solution.     (See  Operations.) 

The  foot  of  the  bed  should  be  raised  on  a  chair,  so  as  to  insure 
a  steady  blood-supply  of  the  brain.  The  head  should  never  be  ele- 
vated above  the  level  of  the  bed.  The  patient  should  be  surrounded 
by  half  a  dozen  bottles  or  rubber  bags  filled  w^ith  hot  water.  Great 
care  should,  however,  be  taken  not  to  have  the  water  so  hot  as  to 
burn  the  patient.  If  the  bottle  is  too  hot,  it  should  be  wrapped  up  in 
a  towel.  Rubbing  of  the  skin  and  kneading  of  the  muscles  of  the 
extremities  are  useful  in  bettering  the  peripheral  circulation.  Strong 
spirit  of  ammonia  held  under  the  nose  stimulates  the  nervous 
system. 

Csesarean  section,  both  the  conservative  and  Porro's  operation, 
has  been  successfully  performed  in  several  cases.  The  latter  is 
oftener  indicated  than  the  former.  One  of  the  great  dangers  in  pla- 
centa praevia  is  the  failure  of  the  uterus  to  contract  after  being 
emptied.  Hence  new  hemorrhage  and  often  death.  This  lack  of 
contraction  also  invites  sepsis.  By  removing  the  uterus  we  cut  off 
the  source  of  hemorrhage  and  the  soil  for  infection.  But  Porro's 
operation  offers  the  mother  by  far  not  so  good  chances  as  the  treat- 
ment by  rupture  of  the  ovum,  compression,  dilatation  of  the  cervix, 
and  forceps  delivery.  It  should  therefore  be  reserved  for  cases  in 
which  it  is  impossible  to  arrest  hemorrhage  in  any  other  way,  espe- 
cially primiparae  with  undilatable  cervix  and  a  narrow  vagina.  If 
the  uterus  contracts  well  after  the  removal  of  the  child  and  the 
peeling  off  of  the  placenta,  and  all  hemorrhage  ceases,  the  uterus  may 
be  spared. 

All  those  who  have  advocated  Caesarean  section  have  compared 
the  results  obtained  in  conservative  Caesarean  section  and  Porro's 
operation  when  performed  by  the  greatest  operative  obstetricians  with 
the  old  statistics  of  vaginal  treatment  of  placenta  prasvia  in  promis- 
cuous practice.  By  thus  ignoring  modern  progress  in  the  vaginal 
operation,  their  argument  becomes  unfounded  on  facts.  Caesarean 
section  has  been  performed  six  times  and  Porro's  operation  twice. 
The  maternal  mortality  has  been  three,  or  37 J  per  cent.,  the  infantile 
two,  or  25  per  cent.  Even  if  the  two  cases  are  left  out  because 
recourse  to  the  abdominal  operation  was  had  too  late,  there  still 
remains  one  mother  dead  out  of  six,  or  16|  per  cent,  maternal  mor- 


HEMORRHAGE.  505 

tality.  When  this  is  compared  with  Hofmeier's  and  Pinard's  ma- 
ternal mortality  of  2.1  and  2.6  per  cent,  respectively,  and  the  latter's 
infantile  mortality  of  only  6.8  per  cent.,  Caesarean  section  cannot  be 
looked  upon  as  an  operation  one  should  choose,  except  when  forced 
to  it.  The  saving  of  the  children  does  not  make  up  for  the  greater 
loss  of  the  mothers. 

Later,  when  the  acute  danger  is  passed,  the  patient  should  have 
as  much  albuminous  food — meat,  eggs,  milk,  and  bread — as  she  can 
digest,  extract  of  red  bone  marrow  (3ii-5ss  t.  i.  d),  iron,  manganese, 
arsenic,  ciuinine,  phosphorus  preparations,  strychnine,  and  terraline. 

§  2.  Premature  Detachment  of  Normally  Inserted  Placenta. — 
It  is  not  only  the  placenta  praevia  that  may  cause  ante-partum  hem- 
orrhage. Also  from  the  normally  implanted  placenta  there  may  be 
loss  of  blood  due  to  a  premature  partial  detachment.  The  hem- 
orrhage may  be  external  or  mternal  (concealed),  or  combined  inter- 
nal and  external. 

The  detachment  may  not  implicate  the  border  of  the  placenta.  In 
that  case  there  forms  only  a  more  or  less  large  blood-clot  between 
the  placenta  and  the  uterus,  and  there  is  no  external  hemorrhage.  In 
other  cases  the  blood  may  detach  part  of  the  margin  of  the  placenta ; 
the  blood  peels  the  membranes  from  the  uterine  wall,  and  may  then 
appear  outside.  But  if  the  lower  segment  of  the  uterus  hugs  the 
presenting  part  closely,  it  is  also  possible  that  the  detachment  is 
arrested  there.  Under  such  circumstances  there  may  be  a  very  con- 
siderable loss  of  blood,  although  none  shows  outside.  In  other  cases, 
again,  a  small  part  of  the  extravasated  blood  may  find  its  way  out, 
while  by  far  the  larger  portion  is  retained  in  the  body  of  the  patient. 
The  blood  rarely  ruptures  the  membranes  and  enters  the  interior  of 
the  ovum.  The  liquor  amnii  being  under  the  same  even  pressure  as 
the  extravasated  blood  resists  its  entrance,  until  the  membranes  are 
ruptured  at  the  lower  pole  of  the  ovum  and  the  liquor  amnii  escapes. 
A  considerable  amount  of  blood  may  also  fill  the  fundal  region  of  the 
uterus. 

This  premature  detachment  of  the  placenta  may  take  place  dur- 
ing the  latter  months  of  pregnancy,  when  the  extravasated  blood  will 
cause  irritation  and  bring  on  labor ;  or  it  may  occur  after  labor  has 
begun. 

Etiology. — The  predisposing  cause  of  the  detachment  is  a  diseased 
condition  of  the  villi  of  the  chorion  or  of  the  docidua  serotina,  which 
often  is  found  in  a  state  of  inflanmiation.  This  condition  is  in  most 
cases  allied  to  nephritis  or  to  the  presence  of  a  kidney  of  pregnancy. 
Acute  infectious  diseases  are  frequently  the  cause.  It  has  also  been 
found  in  connection  with  exophthalmic  goitre  (Graves's  disease).  A 
deep  seat  of  the  placenta  seems  to  predispose  to  the  detachment. 


506  ABNORMAL   LABOR. 

Women  who  have  borne  many  children  are  more  inclined  to  this 
accident  than  primiparae,  which,  doubtless,  is  due  to  an  inferior  con- 
dition of  the  endometrium.  General  weakness  and  anaemia  are  also 
predisposing  factors.  Sometimes  injury  is  the  direct  cause  of  the 
detachment,  such  as  a  fall,  a  kick,  or  similar  violence,  or  undue 
exertion  on  the  part  of  the  patient  in  lifting  heavy  weights.  Violent 
uterine  contraction  may  prematurely  diminish  the  size  of  the  placental 
site  so  much  that  the  placenta  is  loosened  from  its  base.  During  labor 
the  detachment  may  be  due  to  a  sudden  diminution  of  the  size  of 
the  uterus,  such  as  happens  in  hydramnion,  or  after  the  birth  of  the 
first  child  in  twin  pregnancies. 

Symptoms. — If  there  is  no  external  hemorrhage  to  call  attention 
to  the  concealed  hemorrhage,  other  symptoms  become  so  much  more 
important.  The  patient  experiences  a  sudden  abdominal  pain.  The 
uterus  may  become  much  enlarged,  or  it  may  assume  an  irregular 
shape.  There  is  a  sudden  collapse,  the  patient  gasps  for  air,  and  her 
skin  becomes  pale,  cold,  and  clammy.  Uterine  contractions  are  weak 
or  absent  altogether.  There  may  be  circumscribed  tenderness  of 
portions  of  the  uterus.  Since  the  foetus  soon  dies,  fetal  movements 
cease.  If  there  is  an  external  discharge  of  blood,  or  at  least  of 
bloody  serum,  that  corroborates  the  diagnosis.  In  rare  cases  the 
placenta,  as  in  placenta  previa,  may  be  wholly  detached  and  ex- 
pelled ahead  of  the  child,  so-called  prolapse  of  the  placenta. 

Diagnosis. — Premature  detachment  of  the  normally  inserted  pla- 
centa can  hardly  be  confounded  with  anything  else  than  common 
syncope  or  rupture  of  the  uterus.  In  syncope  all  the  local  changes 
are  absent.  In  rupture  of  the  uterus  the  presenting  part  recedes  and 
enters  the  abdominal  cavity,  where  it  may  be  felt.  The  uterus  be- 
comes contracted  and  diminished  in  size,  while  in  placental  detach- 
ment there  are  weak  contractions  or  none  and  a  distention  of  the 
uterine  cavity. 

Prognosis. — The  prognosis  is  bad  for  both  mother  and  child.  In 
106  cases  collected  by  the  late  Dr.  William  Goodell,  of  Philadelphia, 
out  of  107  children  only  6  survived,  and  of  the  mothers  54  were  lost. 
The  external  hemorrhage  is  less  dangerous  than  the  concealed,  since 
with  the  former,  as  a  rule,  some  uterine  contraction  will  set  in  and 
moderate  the  loss  of  blood. 

Treatment. — The  first  step  is  to  rupture  the  membranes,  so  as  to 
diminish  the  uterine  cavity.  The  next  indication  is  to  empty  the 
uterus  as  soon  as  possible.  If  the  head  is  engaged,  this  may  be  done 
by  applying  the  forceps  ;  but  in  most  cases  podalic  version  must  be 
performed,  which,  in  this  case,  unlike  placenta  praevia,  should  be 
followed  immediately  by  extraction  of  the  child  and  removal  of  the 
placenta. 


HEMORRHAGE.  507 

If  the  OS  is  not  dilated,  tlie  accouclu'ur  should  try  to  open  it  by 
Harris's  or  Bonnaire's  method,  or,  if  the  upper  part  of  the  cervix 
is  dilated  and  the  os  resists  dilatation,  two  to  four  deep  incisions 
should  be  made  in  the  cervix  up  to  the  vaginal  roof.  If  they  bleed 
after  the  removal  of  foetus  and  placenta,  they  should  be  closed  with 
sutures. 

After  version  is  performed  or  during  the  application  of  the  obstet- 
ric forceps,  full  doses  of  ergot,  adrenalin,  or  stypticin  should  be  given. 

If  the  patient  when  first  seen  is  very  much  affected  by  pain  and 
loss  of  blood,  it  may  be  necessary  to  stimulate  her  with  strychnine, 
nitroglycerin,  cligitaHs,  or  alcohol  before  exposing  her  to  the  shock 
of  operative  interference  ;  but  the  obstetrician  must  bear  in  mind  that 
the  most  important  means  of  saving  the  patient  is  to  empty  the  uterus 
and  cause  the  uterus  to  contract  well  by  kneading  it,  injection  of  hot 
water,  alcohol,  vinegar,  undiluted  tincture  of  iodine,  or  the  applica- 
tion of  a  faradic  current  of  electricity.  If  the  bleeding  still  continues, 
the  cavity  should  be  injected  with  liquor  ferri  chloridi,  diluted  with 
ten  parts  of  water,  or  ferripyrine  in  a  similar  sol ul ion. 

§  3.  Rupture  of  the  Circular  Sinus  of  the  Placenta. — The 
circular  sinus  forms  a  more  or  less  complete  venous  vessel  in  the 
circumference  of  the  placenta.  It  belongs  to  the  maternal  part  of 
the  placenta.  It  is  formed  by  the  fusion  of  five  or  six  large  venous 
sinuses,  and  is  somewhat  uneven  in  calibre,  one  part  being  more  volu- 
minous than  another.  It  may  form  a  complete  circle  or  be  inter- 
rupted in  places.  When  distended  with  blood,  it  may  swell  to  the 
size  of  a  little  finger.  On  the  cut  surface  it  shows  a  triangular  lumen. 
One  side  is  in  contact  with  the  decidua,  another  with  the  chorion,  and 
the  third  is  full  of  openings,  like  a  sieve,  leading  into  the  sinuses  be- 
tween the  cotyledons.  It  plays  the  role  of  a  reservoir  in  which  the 
surplus  of  blood  finds  room  when  pressed  out  of  the  placenta. 

Etiology. — This  circular  sinus  may  rupture  on  account  of  too  great 
internal  pressure,  so  much  more  so  as  some  parts  of  its  course  are 
narrower  than  others.  Or  it  may  be  torn  when  the  rupture  in  the 
membranes  extends  to  it.  This  accident  is  most  commonly  combined 
with  placenta  praevia  or  the  premature  detachment  of  a  normally  sit- 
uated placenta,  and  is  then  apt  to  be  overlooked.  But  the  rupture 
of  the  sinus  may  also  occur  as  the  only  source  of  hemorrhage  (Fig. 
389).  It  may  arise  during  pregnancy  or  during  labor.  A  diseased 
condition  of  the  decidua  renders  the  wall  weaker,  and  thus  facilitates 
rupture.  Any  physical  injury,  an  over-exertion,  or  uterine  contrac- 
tions during  labor  may  furnish  the  exciting  cause. 

Symptoms  and  Diagnosis. — As  a  rule,  the  placenta  is  in  cases  of 
rupture  of  the  circular  sinus  situated  low  down  in  the  uterus.  The 
blood  therefore  finds  an  easy  outlet  through  the  os.     There  is  no 


508 


ABNORMAL   LABOR. 


distention  of  the  uterus,  and  no  pain  as  in  detachment  of  the  nor- 
mally inserted  placenta.  Since  the  blood  is  not  retained  in  the  inte- 
rior of  the  uterus,  it  has  a  bright  red  color.  As  a  rule,  the  loss  of 
blood  is  moderate,  but  the  hemorrhage  may  become  dangerous  by  its 
steadiness.  There  is  not  that  sudden  collapse  as  in  detachment  of 
the  placenta,  and  the  physical  signs  of  j^lacf^nta  j)rcevia  are  absent. 
When  the  afterbirth  is  examined  a  small  round  opening  or  a  tear  will 
be  found  in  the  sinus,  and  often  a  blood-clot  extending  in  its  interior 
and  plugging  the  aperture. 

Prognosis. — The  prognosis  for  the  mother  is  better  than  in  pla- 
centa prsevia  and  in  premature  detachment  of  the  normally  inserted 

Fig.  389. 


3  2 

Rupture  of  the  circular  sinus  of  the  placenta.    (Budin.)    1,  umbilical  cord  ;  2,  cotyledons  ; 
3,  circular  sinus  ;  4,  blood-clot. 

placenta.  The  hemorrhage  generally  stops  spontaneously  by  the 
formation  of  a  blood-clot.  The  hemorrhage  is  visible  and  not  very 
abundant.  For  the  foetus  the  prognosis  is  less  good,  since  it  may  die 
from  asphyxia,  or  has  to  be  sacrificed  in  order  to  save  the  mother. 

Treatment. — If  the  foetus  is  not  yet  viable,  we  should  try,  if  possible, 
to  postpone  delivery.  Rest  in  bed,  opiates,  viburnum  prunifolium, 
vaginal  suppositories,  with  tannin  or  pledgets  dipped  in  diluted  liquor 
ferri  chloridi  in  the  upper  part  of  the  vagina,  should  be  tried.  Hot 
injections  and  tamponade  are  too  apt  to  induce  labor,  and  can  there- 
fore not  be  recommended  as  long  as  there  is  hope  of  postponing  it. 
But  if  the  hemorrhage  continues  the  uterus  must  be  emptied ;  and 
then  tamponade  is  the  best  preparatory  step,  since  it  at  the  same 
time  arrests  hemorrhage. 


HEMORRHAGE.  509 

If  the  foetus  is  viable  the  membranes  should  be  ruptured  at  once, 
and  if  the  hemorrhage  does  not  stop  labor  should  be  furthered  by 
the  means  enumerated  above. 

§  4.  Rupture  of  Umbilical  Vessels  in  Velamentous  Inser- 
tion.— If  the  umbilical  vessels  spread  over  that  portion  of  the  ovum 
which  has  to  be  torn  to  let  the  child  pass,  they  may  be  ruptured  and 
give  rise  to  hemorrhage  ;  or  they  may  be  compressed  between  the  pre- 
senting part  and  the  pelvic  brim.  In  both  cases  the  child  is  in  great 
danger  either  from  loss  of  blood  or  from  asphyxia. 

Diagnosis. — This  condition  may  be  diagnosticated  if  one  feels  a 
pulsating  vessel  traversing  the  bag  of  waters. 

Ti^eatment. — The  rupture  of  the  membranes  should  be  postponed 
till  the  OS  is  wide  enough  to  end  labor.  For  this  purpose  a  colpeu- 
rynter  is  placed  in  the  vagina  and  moderately  distended  so  as  to  fur- 
nish equal  counter-pressure  to  the  pressure  under  which  the  liquor 
amnii  is  from  within. 

When  the  os  is  sufficiently  dilated,  the  child  should  be  extracted 
by  forceps  or  version. 

§  5.  Post-partum  Hemorrhag-e. — After  the  birth  of  the  child, 
hemorrhage  may  be  primary  or  secondary.  Primary  hemorrhage 
may  occur  before  or  immediately  after  the  expulsion  of  the  placenta. 
Secondary  hemorrhage  may  set  in  after  an  interval  extending  from 
hours  to  weeks.  The  primary  hemorrhage  may  be  due  to  lack  of 
uterine  contraction  or  to  injuries  sustained  by  the  soft  parts — lacer- 
ations of  the  cervix,  the  vagina,  or  the  vulva.  Of  these  two  categories 
that  produced  by  atony,  or  inertia  of  the  uterine  musculature,  is  by 
far  the  more  dangerous. 

We  know  that  the  uterine  veins  become  much  enlarged  during 
pregnancy,  and  form  large  spaces,  so-called  sinuses.  These  are  em- 
bedded in  the  depth  of  the  muscular  coat  of  the  uterus,  each  fibre 
of  which,  as  we  know,  becomes  enormously  hypertrophied  during 
pregnancy,  and  which  forms  three  powerful  layers  compressing  the 
uterus  in  all  directions  (p.  88).  In  the  absence  of  contraction  the 
sinuses  form  large  tubes  with  oval-shaped  lumina,  but  during  con- 
traction they  are  compressed  to  flat  lines,  as  seen  in  Fig.  118. 

In  normal  labor  the  contractions  press  the  walls  of  the  sinuses 
against  each  other  till  they  agglutinate  and  partially  become  imper- 
meable, or  where  they  open  on  the  free  surface,  at  the  placental  site, 
they  are  compressed  long  enough  to  give  time  for  the  blood  to  coagu- 
late in  their  interior.  Under  these  normal  conditions  the  loss  of 
blood  during  and  after  the  third  stage  of  labor  is,  therefore,  moderate 
and  harmless.  But  if  this  harmony  is  disturbed,  if  the  uterus  does  not 
contract,  the  blood  may  pour  out  of  the  parturient  canal  in  a  torrent, 
and  the  patient  succumb  in  a  few  minutes.     These  extreme  cases  are, 


510  ABNORMAL    LABOR. 

however,  rare ;  but  more  or  less  serious  post-partum  hemorrhage  is 
by  no  means  infrequent. 

Etiology. — This  accident  is  comparatively  common  among  women  of 
the  higher  classes,  who  lead  a  life  of  leisure,  have  little  developed  mus- 
cles and  an  over-sensitive  nervous  system.  Sickly  or  anaemic  women, 
who  have  a  poor  constitution,  are  more  liable  to  uterine  inertia  than 
their  healthier  and  more  robust  sisters.  The  event  is  observed  more 
frequently  in  hot  climates,  at  least  in  women  who  are  not  acclimated. 
It  is  described  as  a  positive  danger  in  store  for  English  women  so- 
journing in  East  India,  and  a  similar  experience  may  be  expected 
when  American  women  follow  our  armies  to  the  newly-acquired  pos- 
sessions in  the  tropical  regions  of  the  Atlantic  and  the  Pacific. 

Anything  that  causes  defective  uterine  contraction  is  apt  to  lead 
to  post-partum  hemorrhage.  Multiparous  women  are  more  exposed 
than  others,  doubtless  on  account  of  a  deterioration  of  the  uterine 
muscle-fibres.  Previous  hard  labors  seem  especially  to  predispose  the 
patient  to  post-partum  hemorrhage.  There  may  be  an  original  weak- 
ness of  the  musculature,  which  is  particularly  found  in  bicornute 
uteri.  The  contractive  force  may  be  exhausted  by  a  protracted  labor. 
Great  distention  of  the  uterus,  as  in  hydramnion  or  in  twin  pregnan- 
cies, predisposes  to  it.  Likewise  sudden  evacuation  of  the  uterus,  as 
in  precipitate  labor,  rapid  forceps  delivery,  or  extraction  after  version. 
Retention  or  adhesion  of  the  placenta  or  membranes,  especially  of 
placentae  succenturiatse,  is  a  frequent  cause  of  hemorrhage.  Improper 
treatment  of  the  third  stage  of  labor  may  directly  induce  it.  Not 
only  the  old-fashioned  pulling  on  the  umbilical  cord  is  objectionable ; 
but  even  the  expression  method,  if  used  before  there  is  a  spontaneous 
contraction  of  the  uterus,  is  likely  to  loosen  parts  of  the  placenta  from 
the  uterine  wall  while  the  more  intimately  connected  portions  remain 
adherent,  A  distended  bladder  or  loaded  bowel  may  also  interfere 
with  uterine  contraction  and  cause  hemorrhage.  In  a  pendulous  ab- 
domen the  uterus  is  not  properly  supported  and  abdominal  pressure 
is  weak.  The  use  of  chloroform  in  large  quantity  weakens  the  uterine 
contractions  and  is  a  frequent  cause  of  post-partum  hemorrhage. 

Uterine  contraction  may  be  irregular,  so  that  one  part  of  the 
uterus  is  more  contracted  than  another.  Thus  we  have  seen  above 
(p.  360)  that  there  may  be  a  tetanic  contraction  at  the  contraction 
ring,  which  may  cause  retention  of  the  placenta.  Sometimes  the 
placental  site  remains  lax — so-called  paralysis  of  the  jjlacental  site — 
while  the  surrounding  tissue  contracts,  the  result  being  that  that  part 
of  the  uterus  where  the  serotina  was  inserted  bulges  inward  into  the 
uterine  cavity  and  may  become  the  starting-point  of  inversion. 

Some  women  seem  to  have  a  peculiar  predisposition  to  flooding, 
perhaps  due  to  haemophilia. 


HEMORRHAGE.  511 

Symptoms. — Great  loss  of  blood  has  a  terrible  effect  on  the  patient. 
She  turns  pale ;  her  skin  becomes  cold  ;  perspiration  pearls  out  on 
it ;  she  sighs,  yawns,  and  gasps  for  air.  Restlessly  she  tosses  about 
on  her  bed  and  throws  up  her  arms.  The  pulse  becomes  thready  or 
insensible.  The  patient  complains  of  faintness  or  may  become  un- 
conscious. She  may  become  blind.  Convulsions  may  break  out,  and 
death  may  finish  the  scene. 

If  the  hemorrhage  is  not  so  profuse,  the  uterus  may  alternately 
contract  and  relax.  From  time  to  time  large  clots  followed  by  fluid 
blood  are  expelled. 

After  severe  loss  of  blood,  the  patient  long  remains  weak  and 
anaemic.  It  may  take  months  and  even  years  before  she  quite 
recovers. 

Diagnosis. — A  point  of  great  practical  importance,  and  which 
must  be  settled  at  once,  is  whether  the  source  of  the  hemorrhage  is 
the  interior  of  the  uterus — that  is,  the  placental  site — or  some  tear 
in  the  cervix,  the  vagina,  or  the  vulva,  especially  the  perineum.  This 
question  is  promptly  answered  by  palpating  the  womb.  If  it  is  small, 
hard,  and  well-contracted,  the  body  of  the  uterus  may  be  excluded, 
and  we  may  search  for  injuries.  By  spreading  open  the  vulva  we  see 
the  perineal  body  and  a  part  of  the  vagina.  With  the  finger  we  may 
feel  tears  higher  up  in  the  same  or  in  the  cervix.  By  turning  the 
patient  on  her  left  side  and  introducing  Sims's  speculum  and  retractors 
the  spurting  vessel  may  be  seen  and  made  accessible  to  treatment. 

Another  distinctive  point  is  the  character  of  the  hemorrhage. 
If  the  source  is  an  injury  to  the  soft  parts,  the  flow  is  much  less  ;  it  is 
steady,  the  blood  has  a  bright  red  color,  it  is  fluid ;'  while  in  intra- 
uterine hemorrhage  the  loss  of  blood  is  much  larger,  the  flow  is,  as  a 
rule,  interrupted,  the  color  is  darker,  and  from  time  to  time  clots  are 
expefled. 

If  we  feel  the  uterus  large,  soft,  and  flabby,  the  blood  comes  from 
the  interior,  and  no  time  should  be  lost  in  looking  for  other  sources, 
which  may  be  attended  to  later,  whereas  the  uterine  hemorrhage  is 
an  urgent  indication  for  immediate  therapeutic  action. 

Treatment. — The  treatment  is  partly  prophylactic,  partly  curative. 
Much  can  be  done  to  prevent  post-partum  hemorrhage,  and  it  may 
even  be  said  that  with  proper  management  of  labor  the  event  is  rare 
and  may  never  be  seen  in  its  higher  degrees.  From  the  moment  the 
child  is  born  till  at  least  half  an  hour  after  the  placenta  is  delivered, 
the  fundus  of  the  uterus  should  be  held  \vithout  interruption  by  the 
hand  of  the  obstetrician  or  the  nurse.  When  it  is  properly  con- 
tracted, nothing  more  should  be  done.  But  the  moment  it  is  felt  to 
soften,  the  abdominal  wall  should  be  moved  gently  from  side  to  side 
and  from  the  front  to  the  back  and  vice  versa.     In  this  way  a  mild 


512  ABNORMAL    LABOR. 

tickling  of  the  peritoneal  surface  of  the  fundus  is  produced,  which 
may  be  all  that  is  needed  to  call  forth  renewed  powerful  contractions. 
If  that  does  not  suffice,  the  womb  may  be  kneaded  and  squeezed 
with  the  same  hand. 

The  pulse  gives  sometimes  a  warning  of  impending  danger.  In 
normal  deliveries  it  drops  to  70  or  60  beats  in  a  minute.  If  it  ranges 
from  100  to  120  the  obstetrician  should  be  particularly  watchful,  and 
should  under  no  circumstance  leave  the  patient. 

The  rectum  should  always  be  emptied  before  labor.  A  full  blad- 
der should  be  evacuated  Avith  the  catheter,  unless  the  patient  can 
micturate. 

If  the  hemorrhage  is  not  serious,  the  uterus  need  not  be  entered. 
It  suffices  to  compress  the  fundus.  As  soon  as  there  are  contrac- 
tions, the  accoucheur  should  try  to  press  the  placenta  out  by  Crede's 
method.  Blood-clots  are  likewise  pressed  out  from  above  or  helped 
out  by  introducing  one  finger  into  the  os.  But  if  this  does  not  arrest 
the  hemorrhage,  the  well-disinfected  hand  should  be  introduced  and 
the  placenta  removed  as  described  above  (p.  419). 

The  aorta  can  easily  be  felt  and  compressed  against  the  vertebral 
column  a  little  above  the  promontory.  This  procedure  does  not  shut 
off  the  blood  supply  of  the  uterus,  since  there  comes  as  much  blood 
through  the  ovarian  artery  as  through  the  uterine ;  but  it  diminishes 
the  supply  by  one-half,  and  once  located,  the  artery  may  be  com- 
pressed by  an  unskilled  assistant,  while  the  doctor  is  otherwise  en- 
gaged in  the  interest  of  the  patient. 

The  uterus  itself  may  be  powerfully  compressed  by  pushing  two 
fingers  up  in  the  posterior  vault  of  the  vagina,  against  the  posterior 
wall  of  the  uterus,  and  forcing  the  fundus  down  with  the  other  hand. 
Sometimes  the  compression  can  be  made  even  more  effectual  by  plac- 
ing the  inner  fingers  against  the  anterior  vault  so  as  to  reach  the 
anterior  wall  of  the  anteflexed  uterus. 

Both  the  extremes  of  temperature  are  exciters  of  uterine  contrac- 
tion ;  but  there  is  this  difference,  that  a  low  temperature  weakens  the 
patient,  who  is  already  cold  and  exhausted  by  loss  of  blood,  while  a 
high  temperature  is  a  powerful  restorative.  Cold  should  therefore 
be  applied  only  in  a  transient  way.  A  towel  may  be  wrung  out  of  ice 
water  and  used  for  slapping  the  lower  part  of  the  abdomen  in  front 
of  the  uterus.  Heat  may  be  applied  in  the  shape  of  intra-uterine 
injection  of  hot  water  (110-115°  or  even  120°  F.).  Although  this  is 
very  painful,  the  patient  must  stand  it.  There  is  no  time  for  admin- 
istering an  anaesthetic,  and,  besides,  it  is  too  dangerous. 

All  the  remedial  resources  so  far  considered  aim  at  the  establish- 
ment or  strengthening  of  uterine  contraction,  a  physiological  act  which 
will  in  the  vast  majority  of  cases  result  in  arrest  of  the  hemorrhage. 


HEMORRHAGE.  513 

If,  however,  the  flow  continues,  another  class  of  remedies  is  at 
our  disposal,  those  which  chiefly  act  in  a  chemical  way,  by  causing 
the  blood  to  coagulate.  Instead  of  using  plain  hot  water,  the  writer 
employs  an  emulsion  of  creolin  (one  per  cent.),  which  is  both  astrin- 
gent and  antiseptic.  An  ounce  of  undiluted  tincture  of  iodine  was 
injected  to  great  advantage  by  Dupierris,  a  physician  practising  in  the 
West  Indies,  and  his  example  has  been  followed  by  many  others.  The 
tincture  certainly  coagulates  blood,  and  is  one  of  the  best  antiseptics, 
and  the  coagula  formed  are  not  so  hard  as  those  produced  by  iron  salts. 

The  late  Dr.  R.  A.  F.  Penrose,  of-  Philadelphia,  praised  in  the 
highest  terms  common  vinegar,  both  as  an  irritant  and  as  an  astrin- 
gent. He  recommended  to  pour  a  few  tablespoonfuls  of  vinegar  out 
into  a  vessel,  dip  a  clean  rag  or  pocket-handkerchief  into  it,  carry  it 
with  the  hand  into  the  cavity  of  the  uterus,  and  squeeze  it.  If  neces- 
sary, this  procedure  is  repeated  two  or  three  times.  This  sounds 
rather  antiquated  in  our  days,  when  we  hear  only  of  aseptic  gauze, 
sterilized  fluids,  and  disinfected  hands.  But  I  can  easily  imagine  sit- 
uations in  which  this  old  remedy  may  be  the  best  available  and  may 
save  lives  that  otherwise  would  be  lost.  Advices  that  are  admirable 
in  lying-in  hospitals  and  may  be  followed  to  advantage  in  wealthy 
private  practice,  where  every  possible  event  has  been  anticipated  and 
provisions  made  to  meet  it,  may  not  be  practicable  under  all  circum- 
stances. Let  us,  for  instance,  take  the  case  of  a  physician  called  in  a 
hurry  by  a  midwife,  whose  patient  is  bleeding  to  death.  Under  such 
circumstances  it  Avould  be  folly  to  abstain  from  acting  because  of  the 
remote  danger  of  infection.  The  present  danger  of  collapse  and 
death  from  loss  of  blood  is  the  issue  to  be  met,  and  perhaps  it  is  well 
then  to  think  of  the  old  time-honored  vinegar,  which  is  found  in  every 
dwelling,  can  be  applied  without  apparatus,  excites  the  uterus  to  con- 
traction, coagulates  albumen,  and  even  has  antiseptic  properties. 

I  purposely  keep  the  liquor  ferri  chloridi  for  the  last.  I  carry  it 
always  in  my  satchel,  but  I  do  not  think  that  I  have  ever  used  it  in 
an  obstetric  case.  It  is  a  most  powerful  styptic,  and  by  the  chlorine 
it  contains  it  has  also  antiseptic  value ;  but  the  coagula  produced  by  it 
are  hard  and  slow  to  disintegrate,  and  before  their  removal  they  are 
apt  to  become  infected.  I  look,  therefore,  upon  this  remedy  as  a  last 
resort,  to  be  used  only  when  everything  else  fails.  It  may  be  used  as 
intra-uterine  injection  diluted  with  from  six  to  ten  parts  of  water  or 
squeezed  out  undiluted  from  a  pad  carried  up  to  the  fundus.  After 
having  used  a  styptic,  the  uterus  should  no  longer  be  compressed,  as 
the  compression  might  lead  to  the  detachment  of  a  thrombus,  and 
thus  start  the  bleeding  again. 

Of  late  the  extract  of  tlie  suprarenal  capsule  has  been  much 
praised  for  any  kind  of  hemorrhage.     It  is  said  both  to  be  astringent 

33 


514  ABNORMAL  LABOR. 

and  to  cause  uterine  contraction.  Dr.  James  B.  Moore  dissolved  3iii 
of  Armour's  pulverized  extract  in  sviii  of  -water  and  filtered  it  through 
sterile  gauze.  In  this  he  dipped  a  strip  of  gauze  three-fourths  of  an 
inch  (two  centimetres)  wide  and  one  and  one-half  yards  long,  and 
packed  it  all  into  the  uterus,  removed  it  shortly  after,  and  washed 
out  with  sterile  water.  Simultaneously  he  gave  gr.  x  of  the  extract 
by  the  mouth.  The  htemostatic  effect  of  the  drug  when  used  locally 
or  internally  is  said  to  occur  in  less  than  a  minute.^  Parke,  Davis  & 
Co.  have  two  preparations. — solution  adrenalin  chloride  1  :  1000,  and 
suprarenal  liquid  with  chloretone, — either  of  wdiich  may  be  adminis- 
tered internally  in  doses  of  n\^v-xxx. 

Stypticin  given  internally  in  doses  of  gr.  |-1  (from  3  to  6  centi- 
grammes) or  hypodermically,  dissolved  in  water,  in  doses  of  gr.  i-|- 
(1-2  centigrammes)  and  repeated  according  to  circumstances  is  also 
a  valuable  haemostatic.     It  is  said  also  to  be  analgesic. 

If  an  electric  battery  is  available,  it  should  be  used  at  an  early 
date.  Either  the  faradic  current  or  the  interrupted  battery  current 
may  be  applied  to  great  advantage.  One  pole  should  be  placed  at 
the  fundus  and  the  other  alternately  at  either  side  of  the  cervix 
through  the  abdominal  wall,  where  it  will  reach  the  large  cervical 
ganglion  that  is  in  connection  with  most  of  the  nerves  supplying  the 
uterine  muscle  bundles.  It  is  probably  the  most  powerful  exciter  of 
uterine  contractions.  As  soon  as  the  uterus  is  empty,  some  prepara- 
tion of  ergot  should  be  given  hypodermically. 

Besides  these  measures  directly  aiming  at  uterine  contraction  and 
coagulation  of  the  blood  in  the  veins  of  the  placental  site,  there  are 
others  which  may  be  attended  to  simultaneously.  The  windows 
should  be  opened ;  the  patient  should  be  fanned.  If  pure  oxygen  is 
available,  it  should  be  administered.  The  foot  end  of  the  bed  should 
be  raised,  with  a  view  to  causing  the  blood  in  the  body  to  gravitate 
towards  the  brain.  All  four  extremities  may  be  wrapped  up  in  roller 
bandages,  beginning  from  the  distal  end  and  ending  with  circular  com- 
pression of  the  arms  and  legs  near  the  axilla  and  the  groins.  By 
this  means — so-called  auto-infusion — the  blood  is  concentrated  around 
the  vital  organs, — the  heart,  the  lungs,  and  the  brain. 

Transfusion  of  defibrinated  blood  from  another  individual  is 
effective,  but  takes  much  time  and  is  not  easily  obtained.  Much 
simpler  is  the  intravenous  or  subcutaneous  injection  of  normal  salt 
solution.     (See  Operatioxs.) 

Strychnine,  nitroglycerin,  digitalis,  or  atropine  should  be  injected 
hypodermically  as  stimulants  for  heart  and  lungs.     Strong  spirits  of 

1  J.  B.  Moore,  private  communication  ;  W.  H.  Bates,  N.  Y.  Med.  Record, 
February  9,  1901,  vol.  lix.,  No.  6,  p.  207  ;  E.  A.  Shafer,  British  Medical  Journal, 
April  27,  1901. 


HEMORRHAGE.  515 

ammonia  should  be  held  near  the  nostrils.  Camphorated  oil  may  be 
injected  into  the.  muscles. 

When  the  imminent  danger  is  passed,  the  patient  should  be 
watched,  and  the  injection  of  normal  salt  solution  or  the  administra- 
tion of  the  above-mentioned  drugs  should  be  repeated  until  all  danger 
is  passed. 

After  emptying  the  uterus,  it  has  been  recommended  to  pack  it 
and  the  vagina  with  iodoform  gauze.  So  large  a  quantity  may  be 
needed  for  this  purpose  that  it  may  not  be  without  danger  from  the 
poisonous  quality  of  the  iodoform,  which  would  be  obviated  by  taking 
sterilized  gauze.  The  method  has  met  with  favor,  but  seems  to 
be  inferior  to  the  other  methods  recommended  above.  It  is  more 
rational  and  more  in  harmony  with  nature's  own  methods  to  rely  on 
contraction  and  coagulation  without  leaving  any  foreign  body  in  the 
uterus.  Tamponing  is  in  most  cases  surperfluous.  It  is  not  reliable, 
and  it  contains  an  element  of  danger  as  to  sepsis.  At  all  events,  this 
method  should  be  reserved  for  cases  where  the  hemorrhage  resists  all 
other  treatment,  and  then  I  take  it  to  be  better  to  soak  some  of  the 
gauze  in  diluted  liquor  ferri  chloridi. 

Hemorrhage  is  often  followed  by  a  stage  of  nervous  excitement. 
When  reaction  sets  in,  the  patient  may  suffer  from  intense  throbbing 
headache,  great  intolerance  of  light  and  noise,  or  general  prostration. 
The  best  remedy  for  these  troubles  is  opium. 

When  the  acute  danger  is  over,  attention  should  be  directed  to 
proper  alimentation  and  compensation  for  loss  of  blood.  The  food 
should  be  nitrogenous, — milk,  meat-juice,  and  eggs ;  later,  oysters, 
boiled  sweet-bread,  and,  finally,  poultry,  ham,  and  meat.  At  this 
stage  burgundy  or  port  wine  may  also  be  useful,  while,  as  long  as 
there  is  any  tendency  to  bleeding,  alcohol,  by  increasing  the  inclina- 
tion thereto,  does  harm  and  should  not  be  given,  except  in  the  form 
of  whiskey  or  brandy  as  a  stimulant  to  combat  threatening  collapse. 

Regarding  drugs,  the  extract  of  red  bone  marrow  (carnogen,  hae- 
maboloids)  is  the  most  effective  rebuilder  of  blood  that  I  know  of. 
The  peptonoid  of  iron  and  manganese  (among  the  imported  prepara- 
tions Gude's  and  Diettrich's,  among  the  domestic  feralboids)  is  claimed 
to  be  more  assimilable  than  other  chalybeates.  The  author  has,  how- 
ever, seen  excellent  effect  of — 

R    Solution  ferrous  malate  (Amer.  Pharm.  Mfg.  Co.) 

(or  Tinctura  ferri  pomata  of  the  German  Pharmacopoeia), 
Tinct.  cinchonse  co.,  aa  part.  teq. — M. 

Sig. — A  teaspoonful  three  times  a  day  after  meals. 

With  the  drugs  named  may  also  to  advantage  be  combined  arsenic, 
phosphorus,  cod-liver  oil,  terraline,  and  other  tissue  builders. 


516  ABNORMAL   LABOR. 

Secondary  Hemorrhage. — Hemorrhage  may  recur  within  a  few 
hours  of  the  primary  one,  and  may  then  be  looked  upon  as  a  con- 
tinuation of  the  same  ;  but  it  may  also  appear  weeks  and  even  months 
after  delivery. 

It  may  be  brought  on  by  a  sudden  mental  emotion,  pleasant  or 
unpleasant.  It  may  appear  when  the  patient  suddenly  rises  to  the 
erect  posture  or  strains  herself  in  any  muscular  effort.  Abuse  of 
alcoholic  drinks  is  very  apt  to  lead  to  it.  It  may  be  due  to  sexual 
intercourse.  Albuminuria  or  malaria  may  give  rise  to  it.  Sometimes 
the  cause  is  retention  of  a  piece  of  the  placenta  or  of  the  membranes, 
or  retroflexion  of  the  uterus. 

Treatment. — The  treatment  differs  according  to  the  amount  of 
blood  lost  and  the  cause  of  the  trouble.  A  retroflexed  uterus  should 
be  replaced  and  kept  up  with  a  large  pessary  during  the  period  of 
involution,  at  the  end  of  which  it  is  advisable  to  fasten  the  organ  in 
the  right  position  by  some  suitable  operation.^  If  any  part  of  the 
ovum  is  retained,  it  is  removed  by  curettage."  If  there  is  reason  to 
believe  the  hemorrhage  is  of  malarial  origin,  quinine  and  arsenic  are 
indicated ;  and,  if  possible,  the  patient  should  change  her  residence, 
at  least  temporarily.  Albuminuria  demands  proper  treatment  of  the 
kidneys.  The  bowels  must  be  kept  open.  The  fluid  extract  of  ergot 
should  be  given.  The  writer  has  also  seen  good  effect  of  a  decoction 
of  cotton-root  bark : 

R    Gossypii  radicis  corticis  raspati,  ^iv. 
Sig. — Boil  3  heaping  teaspoonfuls  with  1  pint  of  water  for  15  minutes  ;  strain. 
Drink  one-third,  cold,  three  times  a  day. 

Some  praise  tinctura  cannabis  indicae.  Plain  hot  vaginal  douches 
are  useful  and  may  be  strengthened  by  the  addition  of  liquor  ferri 
chloridi  (gss  to  Oi).  Tannin  pessaries  may  also  be  left  in  the  vagina. 
A  blister  on  the  sacrum  is  said  to  have  a  good  effect.  If  the  hemor- 
rhage is  considerable  and  does  not  yield  to  these  remedies,  the  vagina 
should  be  tamponed,  and  counter-pressure  exercised  over  the  lower 
part  of  the  abdomen. 

§  6.  Inversion  of  the  Uterus. — Inversion  consists  in  the  turn- 
ing inside  out  of  the  uterus.  It  is  said  to  be  so  rare  that  only  one 
case  was  observed  in  200,000  cases  of  confinement  in  the  Rotunda 
of  Dublin.  I  am  inclined  to  think  that  this  is  due  to  the  superior 
method  in  which  normal  labor  has  been  conducted  of  old  in  that 
institution.  Having  personally  seen  at  least  three  cases,  I  cannot 
believe  that  the  accident  should  be  one  of  so  extreme  rarity,  and  most 
authors  speak  of  it  in  terms  of  familiarity.     Still  it  is   undoubtedly 

'  Garrigues,  Diseases  of  Women,  third  ed.,  pp.  471,  474-478. 
2  Ibid.,  p.  180. 


HEMORRHAGE. 


517 


rare,  and  has  become  much  rarer  since  the  management  of  normal 
labor  has  been  improved,  particularly  since  pulling  on  the  umbilical 
cord  has  given  way  to  expression  of  the  placenta. 

Three  degrees  of  inversion  may  be  distinguished.  In  the  first 
there  is  a  mere  indentation  of  the  fundus,  a  bulging  inward.  In  the 
second  degree  (Fig.  390)  the  partially  inverted  uterus  forms  a  tumor 
in  the  vagina.  In  the  third  degree  the  inversion  is  complete  (Fig.  391), 
the  whole  uterus,  inclusive  of  the  cervix,  being  turned  inside  out  and 
forming  a  tumor  outside  of  the  vulva. 


Fig.  390. 


Incomplete  inversion  of  the  uterus.    (Denuc6.) 

Etiology. — The  inversion  may  be  produced  artificially  through 
improper  management,  or  arise  spontaneously.  Under  all  circum- 
stances it  can  only  happen  when  the  placenta  is  not  implanted,  as  it 
normally  is,  on  the  walls  of  the  body,  but  on  the  fundus.  Formerly 
the  placenta  was  removed  by  winding  the  cord  around  the  fingers 
of  one  hand,  and  often  by  pressing  simultaneously  on  the  pla- 
centa in  the  neighborhood  of  the  cord.  If  we  suppose  the  placenta  to 
be  somewhat  adherent  and  the  uterus  not  to  be  well  contracted,  we 
can  easily  imagine  that  the  fundus  might  follow  the  traction  exer- 
cised on  it  from  below  and  become  inverted.  This  movement 
would  be  seconded  if,  instead  of  grasping  the  whole  upper  part  of 
the  uterus,  mere  flat  pressure  were  exercised  on  its  top.  Even  the 
expression  method,  if  not  used  properly,  may  favor  it.     Thus,  if  the 


518 


ABNORMAL    LABOR. 


accoucheur  is  in  too  great  a  hurry  about  expressing  the  placenta,  and 
does  it  in  the  absence  of  a  spontaneous  contraction,  he  may  push  the 
fundus  in. 

But  there  is  no  doubt  that  inversion  may  occur  without  any  fault 
of  the  obstetrician,  the  midwife,  or  the  patient  herself.  In  the  first 
place,  the  accident  is  apt  to  occur  in  cases  of  precipitate  labor,  where 
nobody  touches  the  womb.  In  such  cases  it  is  the  child  dangling 
between  the  legs  of  the  mother  which  pulls  on  the  cord,  and,  if  this 

Fig.  39L 


Complete  inversion  of  tlie  uterus.     (Boivin  and  Duges.) 


does  not  tear  or  the  placenta  become  detached,  the  fundus  may  be 
pulled  down  through  the  contraction  ring.  Secondly,  there  are  nu- 
merous observations  in  which  the  mechanism  could  be  distinctly  felt 
to  consist  in  the  relaxation  of  the  central  part,  corresponding  to  the 
placental  site,  and  strong  contraction  of  the  surrounding  tissue,  so  that 
the  lax  part  sank  inward,  was  seized,  and  was,  so  to  say,  sucked  down 
by  the  contracting  part. 

Inversion  has  been  observed  also  as  a  post-mortem  occurrence, 
the  gases  developed  in  the  abdominal  cavity  having  expansive  power 
enough  to  turn  the  uterus  inside  out. 

Symptoms. — The    inversion   is  often   accompanied  by  a   sudden, 


HEMORRHAGE.  519 

sharp  pain  in  the  abdomen,  but  the  chief  symptom  is  a  post-partum 
hemorrhage  that  may  assume  such  proportions  that  the  patient  faints, 
goes  into  convulsions,  or  even  dies. 

Diagnosis. — By  placing  the  hand  on  the  womb,  it  is  found  bulging 
inward,  or  the  whole  ball  formed  by  the  organ  in  normal  delivery 
may  be  absent.  A  red,  globular,  bleeding  tumor,  covered  with 
mucous  membrane,  may  be  seen  protruding  from  the  genitals ;  or  it 
may  be  felt  with  one  fmger  in  the  vagina  or  in  the  uterus ;  or  if  the 
whole  hand  is  passed  into  the  cavity,  one  may  feel  the  fundus  bulging 
downward. 

The  only  thing  inversion  may  be  confounded  with  is  a  uterine 
polypus,  but  the  differential  diagnosis  is  easily  made  with  a  uterine 
sound,  which  passes  a  polypus  and  ascends  to  the  fundus,  while  in 
inversion  it  is  soon  arrested  by  the  invaginated  uterus.  In  a  case  of 
hollow  polyjnis  the  sound  does  not  enter  the  uterus  either,  but  the 
tumor  contains  fluid,  is  softer  than  the  inverted  uterus,  and  is  an 
exceedingly  rare  affection,  that  by  its  nature  is  excluded  from  a  puer- 
peral case.^ 

Prognosis. — Inversion  is  a  very  dangerous  condition,  which  may 
end  fatally. 

Treatment. — As  soon  as  the  diagnosis  is  made,  the  uterus  should 
be  replaced,  which  is  much  easier  in  the  beginning  than  later. 

If  the  uterus  is  only  indented,  the  hand  must  be  introduced  and 
the  closed  fist  used  to  push  back  the  incurved  portion  of  the  womb. 
If  true  invagination  is  already  accomplished,  the  fmgers  of  one  hand 
should  be  inserted  through  the  abdominal  wall  into  the  funnel-shaped 
depression  formed  by  the  inverted  uterus,  and  excentric  pressure 
should  be  exercised  on  the  ring  encircling  the  invaginated  portion, 
while  the  accoucheur  tries  to  replace  the  prolapsed  portion  with  the 
other  hand.  If  he  should  simply  press  on  the  most  prominent  por- 
tion of  the  tumor  in  the  hope  of  reinverting  it,  he  would  probably 
meet  with  insuperable  resistance,  for  by  so  doing  he  would  create  a 
new  invagination  inside  of  the  other  and  going  in  the  opposite  direc- 
tion. He  has  better  chances  if  he  tries  to  replace  the  uterus,  like  the 
intestine  in  a  hernia,  by  pressing  on  the  part  that  has  come  out  last  and 
trying  to  replace  that  first  and  then  the  next  highest  portion,  and  last 
of  all  the  fundus  (McClintock's  method).  But  the  best  of  all  methods 
is  based  upon  the  known  anatomical  distribution  of  the  fibres  of  the 
inner  layer  of  the  muscular  coat  of  the  uterus  (Fig.  121,  p.  89),  By 
pressing  exclusively  on  the  uterine  opening  of  one  of  the  Fallopian 
tubes,  while  counter-pressure  is  exercised  from  above,  this  horn  may 
be  rein  verted,  thereafter  the  other,  and  finally  the  remainder  of  the 
uterus  (Noeggerath's  method). 

1  Garrigues,  Diseases  of  Women,  third  ed.,  p.  488. 


520  ABNORMAL   LABOR. 

When  the  uterus  is  replaced  it  should  be  manipulated  with  both 
hands,  so  as  to  bring  it  into  a  condition  of  strong  contraction,  which 
should  be  followed  by  a  hot  antiseptic  intra-uterine  injection,  and,  if 
needed,  even  a  styptic  injection.  Besides  replacing  and  kneading  the 
organ,  the  accoucheur  should  use  the  remedies  described  in  treating 
of  post-partum  hemorrhage. 

The  question  presents  itself  how  to  deal  with  the  placenta,  if  that 
is  still  attached  to  the  inverted  wall  of  the  uterus.  Here  the  obstet- 
rician finds  himself  between  the  two  horns  of  a  dilemma.  By  remov- 
ing the  placenta  he  will  diminish  the  surface  to  be  replaced,  but  in 
peeling  it  off  he  may  increase  the  hemorrhage.  If  the  placenta  is 
partially  detached,  it  is  best  to  detach  it  altogether  before  attempting 
reinvagination.  If,  on  the  other  hand,  it  is  still  adherent  all  over,  it  is 
best  to  leave  it  undisturbed  and  try  to  push  it  back  together  with  the 
inverted  portion  into  the  interior  of  the  uterus.  But  if  the  accoucheur 
does  not  succeed  in  his  attempt,  he  should  try  the  other  way  and 
remove  it  first. 

If  reposition  proves  impossible,  a  colpeurynter  filled  with  ice-water 
should  be  placed  in  the  vagina.  This  will  arrest  hemorrhage,  and 
sometimes  at  the  end  of  some  hours  it  may  be  possible  to  replace 
the  uterus.  Before  giving  up  the  case,  the  obstetrician  should  try 
Courty's  method,  in  which  two  fingers  of  the  left  hand  are  introduced 
into  the  rectum,  and  attempt  to  open  the  constricting  ring,  while  the 
fingers  of  the  right  hand  are  made  to  press  on  the  base  of  the  tumor ; 
and  even  the  method  of  Tate,  of  Cincinnati,  who  dilates  the  urethra 
until  he  can  introduce  the  right  index-finger  into  the  bladder  and 
press  on  the  ring  from  this  side,  while  the  left  index-finger  and  mid- 
dle finger  are  used  as  in  Courty's  method  and  the  thumbs  press  on 
the  tumor. 

Whatever  method  is  chosen,  the  operation  is  much  facilitated  by 
anaesthetizing  the  patient,  whereby  not  only  the  element  of  pain  is 
excluded,  but  the  uterus  is  relaxed.  The  only  contra-indication  is  if 
the  patient  is  in  such  a  condition  of  exhaustion  in  consec|uence  of  loss 
of  blood  that  the  use  of  an  anaesthetic  becomes  too  hazardous. 

If  the  case  is  not  seen  before  days  or  weeks  have  elapsed  since 
the  accident  occurred,  reposition  may  still  be  tried,  but  then  the 
prospect  of  its  being  successful  is  much  smaller  than  immediately 
after  delivery.  If  it  does  not  succeed,  protracted  elastic  pressure 
should  be  used,  as  for  incarcerated  retroflexed  uterus  (p.  299).  If 
there  is  any  bleeding,  it  should  be  checked  by  tamponade,  which  at 
the  same  time  prepares  the  uterus  for  reinvagination.  After  the 
lying-in  period,  the  case  passes  into  the  domain  of  gynaecology,  and 
may,  as  a  rule,  be  successfully  treated  by  operation.^ 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  490. 


HEMORRHAGE.  521 

§  7.  Thrombus,  or  Haeraatoma,  of  the  Vulva  and  the  Vagina. — 
A  thrombus,  or  haematoma,  is  an  extravasation  of  blood  into  the  con- 
nective tissue  of  the  parturient  canal.  It  may  be  deej:),  or  interstitial^ 
or  superficial  and  pedunculated.  The  interstitial  haematoma  is  most 
commonly  situated  in  the  labia  majora  of  the  vulva,  more  rarely 
around  the  vagina,  and  least  frequently  on  the  wall  of  the  upper  part 
of  the  pelvis.  The  seat  and  extension  of  the  haematoma  depend 
upon  the  source  of  the  extravasated  blood.  If  this  is  situated  below 
the  pelvic  fascia,  the  blood  accumulates  in  one  labium  majus,  but 
may  extend  to  the  perineum  and  surround  the  anus.  Or  it  may  be 
found  on  one  side  of  the  vagina  or  surround  it  more  or  less  com- 
pletely. If,  on  the  other  hand,  rupture  takes  place  between  the  pelvic 
fascia  and  the  peritoneum,  the  blood  may  ascend  to  the  iliac  fossa  and 
thence  to  the  region  of  the  kidney  or  in  front  up  to  the  umbilicus. 
Very  rarely  there  are  two  collections  of  blood,  which  may  even  com- 
municate so  as  to  form  an  hour-glass-shaped  cavity. 

The  blood  is  at  first  fluid,  but  coagulates  later.  It  may  become 
absorbed,  or  the  tumor  may  rupture,  form  an  abscess,  or  become 
gangrenous. 

The  formation  of  a  thrombus  is  a  rather  rare  affection,  occurring 
on  an  average  only  once  in  1500  confinement  cases. 

Etiology. — Little  is  known  about  the  cause  of  a  haematoma.  So 
much  is  sure  that  varicose  veins,  which  are  so  common,  have  nothing 
to  do  with  it.  During  pregnancy  it  is  rather  rare  and  of  minor 
importance.  The  same  appUes  to  the  puerperal  state.  It  is  by  far 
more  common  and  more  important  during  labor.  The  inherent  con- 
gestion of  the  genitals  may  predispose  to  it,  and  so  may  the  hydraemic 
condition  of  the  blood,  physiologically  found  during  pregnancy ;  but 
the  true  exciting  cause  is,  doubtless,  mechanical.  By  the  pressure 
exercised  by  the  presenting  head  the  tissues  are  torn  asunder  below 
the  integument,  and  the  hollow  thus  formed  fills  with  blood  from  the 
torn  small  arteries,  veins,  and  capillaries.  Sometimes  the  formation 
of  the  thrombus  follows  the  application  of  the  forceps.  When  it 
appears  in  childbed,  it  is  likely  that  the  injury  took  place  during 
labor ;  that  a  small  hsematoma  was  developed,  but  overlooked ;  and 
that  coagula  were  formed  and  later  displaced,  thus  giving  rise  to  new 
extravasation  of  blood. 

Very  rarely  the  haematoma  arises  late  in  the  puerperium,  in  con- 
sequence of  physical  exertion. 

It  has  been  noticed  that  haematoma  is  found  unusually  often  after 
the  birth  of  the  first  child  in  twin  pregnancies,  where  it  probably  is 
due  to  the  rapid  diminution  of  the  uterus  and  passage  of  the  foetus. 

Thrombus  is  more  common  in  pluriparae,  but  not  more  so  than 
one  would  expect  from  their  proportion  to  primiparae.     Sometimes 


522  ABNORMAL   LABOR. 

coition  seems  to  be  the  cause,  which  may  be  explained  both  by  phy- 
sical injury  and  determination  of  blood  to  the  genitals. 

Symptoms. — The  patient  complains  of  a  grinding  pain  in  the  geni- 
tals, sometimes  irradiating  into  the  iliac  fossa  or  higher  up  in  the 
abdomen,  or  down  to  the  knee.  She  feels  a  desire  to  evacuate  the 
bladder  and  the  bowel. 

There  appears  suddenly  a  swelling  in  the  labia  or  in  the  vagina, 
or  in  the  upper  part  of  the  true  pelvis  and  in  the  false  pelvis.  The 
size  of  the  swelling  varies  from  that  of  a  walnut  to  that  of  a  fetal 
head  or  more.  The  skin  or  mucous  membrane  over  it  has  a  purplish 
color.  The  tumor  is  immovable.  At  first  it  is  soft  or  even  fluc- 
tuating. Later  it  becomes  doughy,  then  hard,  and  may  on  pressure 
give  the  crunching  sound  of  a  snowball  being  pressed.  The  tumor 
may  be  reabsorbed,  or,  if  it  suppurates,  it  will  again  soften  and  be- 
come fluctuating.  It  may  also  rupture  and  give  exit  to  blood,  partly 
clotted,  partly  fluid.  The  skin  or  mucous  membrane  covering  it  may 
become  black  and  mortified  and  exhale  a  fetid  odor.  The  hemor- 
rhage, then,  may  remain  internal  or  become  external. 

Diagnosis. — The  pain,  the  sudden  appearance  of  a  tumor,  and 
the  hemorrhage,  be  it  internal  or  external,  are  so  characteristic  that 
hsematoma  can  scarcely  be  confounded  with  anything  else. 

Prognosis. — In  pregnancy  and  the  puerperium  the  prognosis  is 
good,  but  during  labor  the  formation  of  a  hsematoma  is  a  grave  acci- 
dent, that  in  a  large  proportion  of  cases  ends  fatally,  both  for  mother 
and  foetus.  The  danger  for  the  mother  is  commensurate  with  the  size 
of  the  tumor  and  the  loss  of  blood,  whether  it  flows  out  or  remains 
in  the  tissues  of  the  body.  Besides  the  danger  from  loss  of  blood, 
there  is  a  secondary  danger  of  septicsemia. 

The  worst  form  is  the  vaginal  hsematoma  appearing  during  labor, 
because  it  is  apt  to  rupture  spontaneously  or  must  be  opened  in  order 
to  make  room  for  the  foetus. 

Treatment. — If  the  hsematoma  forms  during  pregnancy,  the  patient 
should  be  kept  in  bed,  on  light,  cool  diet.  The  bowels  should  be  kept 
open  M'ith  saline  aperients.  The  skin  and  the  vagina  should  be  dis- 
infected. The  external  genitals  should  be  covered  with  compresses 
wrung  out  of  ice-water  and  constantly  changed,  or,  what  is  more 
convenient,  covered  with  a  rubber  bag  containing  ice.  A  moderate 
pressure  may  also  be  exercised  from  within  by  placing  a  small  bag 
moderately  filled  with  ice- water  in  the  vagina.  The  skin  may  be 
both  hardened  and  disinfected  by  covering  it  with  a  pad  wrung  out 
of  Burow's  solution  (acetate  of  aluminum).  Absorption  may  be 
furthered  by  using  compresses  dipped  in  ice-cold  tinctura  arnicae  or 
extractum  hamamelis  diluted  with  eight  parts  of  water.  Another 
absorbent  highly  praised  by  railroad  surgeons  is — 


HEMORRHAGE.  523 

Ji   Tinct.  capsici, 

Mucilag.  acacias,  aa  ^i; 
Glycerin!,  ^:^ss  ; 

which  is  repeatedly  painted  on  the  skin. 

While  moderate  pressure  furthers  absorption,  any  violence  must 
be  deprecated,  as  it  may  extend  the  blood  farther  away,  displace  clots, 
or  rupture  the  integuments. 

If  an  abscess  forms,  it  should  be  opened,  the  cavity  washed  out 
with  ice-cold  or  very  hot  antiseptic  fluid,  but  the  walls  should  not  be 
scraped  for  fear  of  dislodging  protecting  clots.  The  cavity  should 
be  packed  with  iodoform  gauze  or  sterilized  gauze.  Externally  an 
antiseptic  dressing  with  compression  should  be  applied,  and  changed 
according  to  the  general  rules  of  surgery. 

If  the  haematoma  ruptures  during  pregnancy,  the  opening  should 
be  enlarged,  clots  turned  out,  and  the  cavity  filled  as  just  described. 

During  labor  we  should  as  long  as  possible  try  to  preserve  the 
hsematoma  intact,  and  end  labor  as  soon  as  possible,  but  if  the  tumor 
opposes  an  insuperable  obstacle  to  the  passage  of  the  foetus,  it  must 
be  incised  in  its  most  declivitous  part ;  but,  as  great  hemorrhage  may 
be  expected,  the  obstetrician  must  have  everything  in  readiness  for 
local  and  general  treatment  according  to  the  rules  laid  down  above. 

After  the  delivery  of  the  placenta  it  is  best  to  use  an  expectant 
treatment,  but  if  the  parts  look  gangrenous  it  is  better  to  open  the 
tumor  and  pack  it.  If  the  cavity  is  very  large,  counter-openings  may 
be  made  and  drains  inserted  in  different  directions. 

The  superficial^  pediculated  hcematoma  is  still  rarer  than  the  inter- 
stitial. It  is  always  situated  in  the  median  line  of  the  posterior  wall 
of  the  vagina,  to  which  it  is  attached  by  a  longitudinal  pedicle  (Fig. 
392).  It  is  found  only  during  pregnancy,  and  only  during  the  latter 
part  of  the  same.  It  forms  a  sausage-shaped  mass  in  the  vagina,  and 
is  situated  quite  superficially,  so  as  not  to  implicate  the  rectovaginal 
septum.  On  account  of  this  position  it  is  supposed  to  be  formed 
in  a  remnant  of  the  partition  that  in  early  fetal  life  separates  the  two 
Miillerian  tubes. 

After  a  few  days  the  whole  tumor  falls  off  like  a  ripe  fruit  or 
bursts,  giving  outlet  to  clotted  blood. 

The  superficial  form  is  entirely  benign,  and  does  not  even  call  for 
treatment,  beyond  small  antiseptic  injections  during  the  healing 
process. 

§  8.  Thrombus,  or  Haematoma,  of  the  Cervix. — There  are  a 
couple  of  cases  on  record  in  which  a  hoematoma  formed  in  the  cervix. 
In  one  case  there  was  moderate  hemorrhage  from  a  swollen  cervix  be- 
fore delivery,  which  ceased  when  the  child  was  born.     In  another,  the 


524 


ABNORMAL    LABOR. 


hemorrhage,  which  ended  fatally  in  an  hour  and  a  half,  did  not  appear 
before  five  days  after  delivery.  The  autopsy  showed  the  cervix  to  be 
the  seat  of  a  cavity  of  the  size  of  a  small  orange,  into  which  opened 
several  blood-vessels. 


Superficial  pedunculated  hsematoma  of  the  vagina.    (Tarnier  and  Budin,  1.  c.)     .-1,  the  tumor 
pulled  out  with  a  thumb- forceps  ;  behind  it  is  the  pedicle. 


The  diagnosis  is  made  with  the  finger  and  the  speculum.  Hsema- 
toma  differs  from  rupture  of  the  uterus  by  having  a  closed  cavity,  not 
communicating  with  the  abdomen. 

The  treatment  would  consist  in  a  thorough  tamponade  of  the 
cavity,  the  cervix,  and  the  vagina. 

§  9.  Childbirth  without  Loss  of  Blood. — Some  loss  of  blood 
is  a  normal  feature  of  childbirth.  With  a  macerated  fcetus  bloodless 
delivery  is,  however,  sometimes  observed,  a  phenomenon  which  prob- 
ably is  due  to  the  destruction  of  the  blood-vessels  of  the  decidua  and 
thrombosis  of  the  nlacental  sinuses. 


RUPTURE   OF   ORGANS.  525 

CHAPTER    XI. 

ECLAMPSIA. 

Next  to  hemorrhage  eclampsia  is  the  most  dangerous  compHca- 
tion  of  childbirth,  and  often  the  two  are  combined.  With  respect  to 
this  formidable  disease  the  reader  is  referred  to  what  has  been  said 
above  (p.  325),  when  we  first  met  it  as  an  accompaniment  of 
pregnancy. 

CHAPTER   XII. 

HEART   DISEASE. 

Valvular  heart  disease  is  a  serious  complication  of  labor.  The 
greatest  danger  is  immediately  after  the  birth  of  the  child,  but  the 
views  of  authors  differ  much  as  to  the  real  nature  of  the  trouble. 
Some  think  it  is  due  to  the  diminution  of  abdominal  pressure,  the 
large  vessels  of  the  abdominal  cavity  drawing  the  blood  away  from 
the  heart.  Under  this  theory  the  best  treatment  is  compression  of 
the  abdomen  with  bandages  and  sand-bags. 

Others  have  the  diametrically  opposed  view  that  too  much  blood 
is  thrown  back  on  the  heart,  and,  unless  the  patient  has  already  lost 
much  blood,  their  remedy  is  venesection.  The  former  theory  seems 
much  more  plausible,  and  I  recommend,  therefore,  the  corresponding 
treatment. 

The  efforts  and  fatigues  of  labor  may  in  themselves  overtax  a 
diseased  heart.  No  wonder,  therefore,  that  patients  suffering  from 
valvular  heart  disease  are  liable  to  fainting-spells  and  even  sudden 
death  during  labor.  The  muscular  tissue  of  the  heart  is  even  said 
to  have  undergone  fatty  degeneration  during  pregnancy. 

Labor  should  be  abbreviated  as  much  as  possible.  (Compare 
p.  343). 

CHAPTER    XIII. 
RUPTURE   OF    ORGANS. 

The  force  developed  during  labor  may  be  so  great  that  soft  organs 
rupture,  strong  ligaments  are  torn,  and  even  sohd  bones  are  fractured. 

§  1.  Rupture  of  the  Uterus. — In  speaking  of  rupture  of  the 
uterus,  we  do  not  mean  the  tears  in  the  vaginal  portion,  which  are 
so  common  that  they  almost  may  be  considered  as  an  attribute  of 
normal  childbirth,  or  those  extending  somewhat  higher  up  in  the 
cervix  and  implicating  the  parametrium.  The  lesion  we  now  con- 
template is  a  tear  originating  in  the  supravaginal  portion  of  the  cervix 


526  ABNORMAL   LABOR. 

and  the  lower  uterine  segment,  or  at  the  fundus  of  the  uterus.  The 
tear  may  go  tlirough  the  whole  thickness  of  the  wall — complete  rup- 
ture— or  the  peritoneum  may  resist — internal  incomplete  rupture — or 
the  peritoneum  alone  and  part  of  the  outermost  muscular  fibres  may 
rupture  while  the  uterine  cavity  remains  intact — external  incomplete 
rupture. 

Rupture  of  the  uterus  is  so  rare  an  accident  that  even  experienced 
obstetricians  may  never  have  seen  a  case.  According  to  Dutch  sta- 
tistics, there  was  1  case  in  2333  confinements ;  in  France,  1  in  3403  ; 
and  in  London,  1  in  5495.  In  America  rupture  of  the  uterus  is  still 
rarer  than  in  Europe,  which  must  be  attributed  partly  to  the  com- 
parative rarity  of  the  higher  degrees  of  pelvic  distortion  and  partly  to 
the  fact  that  most  confinements  in  this  country  are  in  the  hands  of 
physicians,  Avho  know  how  to  avert  this  terrible  lesion  by  timely  inter- 
ference. For  the  latter  reason  the  event  is  also  much  rarer  in  lying-in 
institutions  than  in  private  practice. 

The  incident  being  to  a  great  extent  preventable,  the  obstetrician 
in  whose  practice  it  happens  exposes  himself  to  blame,  and  even  to 
a  suit  for  malpractice.  The  general  practitioner  should,  therefore, 
not  be  tempted  by  its  rarity  to  slight  it,  but  should  make  himself 
thoroughly  acquainted  with  its  symptoms  and  treatment.  Personally, 
the  writer  has  operated  on  only  one  case  in  consultation,^  and  in  his 
capacity  as  pathologist  to  the  New  York  Obstetrical  Society  made  a 
circumstantial  report  based  on  macroscopical  and  microscopical  ex- 
amination in  another  case.^ 

Etiology. — The  uterus  may  rupture  during  pregnancy  or  during 
labor.  Rupture  may  occur  as  early  as  the  third  month  of  pregnancy, 
but  is  much  more  common  towards  the  end.  We  have  already  seen 
that  pregnancy  in  the  undeveloped  horn  of  a  bicornute  uterus  and  in 
the  intra-uterine  portion  of  the  tube,  so-called  interstitial  pregnancy, 
is  apt  to  end  in  rupture.  Falls,  kicks,  blows,  and  similar  injuries  may 
cause  it.  In  such  cases  sometimes  the  whole  unruptured  ovum  may 
escape  into  the  abdominal  cavity.  The  cicatrix  after  Caesarean  section 
is  apt  to  give  way  during  a  new  pregnancy.  This  was  particularly  the 
case  formerly  when  no  sutures  were  used,  but  happens  even  nowa- 
days when  the  edges  of  the  incision  in  the  uterus  have  been  caretully 
brought  together.  Sometimes  a  fistula  left  after  Caesarean  section  and 
forming  a  connection  between  the  interior  of  the  womb  and  the  skin 
or  the  bladder  has  given  rise  to  rupture.  In  other  cases  repeated 
removal  of  an  adherent  placenta  seems  to  have  left  the  wall  in  a 
weakened  condition.     In  others,  again,  the  wall  was  the  seat  of  fibrous 

^  Garrigues,  "A  Case  of  Laparotomy  for  Ruptured  Uterus,"  The  Medical 
News,  March  3,  1888,  vol.  lii.,  No.  9,  p.  225. 

^  Garrigues,  Amer.  Jour.  Obst.,  1881,  vol.  xiv.  p.  403. 


RUPTURE    OF    ORGANS.  527 

or  cancerous  degeneration.  It  has  also  been  alleged  that  it  might  be 
in  a  state  of  fatty  degeneration,  but  without  proof.  In  the  speci- 
men that  I  examined  I  paid  special  attention  to  this  point,  and  found 
the  muscular  tissue  entirely  normal.  Insertion  of  the  placenta  at  the 
fundus  has  led  to  overdistention  and  rupture  of  this  part  of  the  uterus. 
Rupture  occurs  much  more  frequently  in  pluripane  and  multiparse 
than  in  primiparae.  Advanced  age  has  unmistakable  influence  as 
a  predisposing  cause,  most  of  the  patients  being  between  thirty  and 
forty  years  old.  Some  cases  are  undoubtedly  due  to  the  administra- 
tion of  ergot  when  there  is  a  mechanical  disproportion.  We  have  also 
seen  that  a  clumsy  use  of  instruments  in  criminal  abortion  may  lead 
to  rupture  of  the  uterus,  with  prolapse  of  the  intestine. 

When  the  foetus  is  pushed  into  the  abdominal  cavity,  in  exceed- 
ingly rare  cases  it  has  become  changed  into  a  lithopaedium.  Still 
rarer  it  continues  to  live  till  the  end  of  pregnancy.  Generally  putre- 
faction sets  in  and  the  patient  dies  of  septic  jneritonitis. 

Rupture  during  labor  is,  however,  by  far  more  frequent  than  that 
during  pregnancy.  The  chief  conditions  that  lead  to  it  are  a  narrow 
pelvis,  neglected  cross-birth,  and  hydrocephalus.  The  mechanism  by 
which  the  rupture  is  produced  is  well  known.  There  being  a  dispro- 
portion between  the  object  propelled  and  the  canal  through  which  it 
should  pass,  the  active  part  of  the  uterus  above  the  contraction  ring 
contracts  more  and  more,  and  pushes  the  foetus  into  the  passive  part, 
— the  lower  uterine  segment  and  the  cervix, — which  becomes  more 
and  more  distended  and  finally  gives  way.  The  chief  seat  of  the  tear 
is  just  below  the  contraction  ring,  on  the  posterior  surface,  on  the 
anterior,  or  on  both  (Fig.  393).  Another  place  of  predilection  is  the 
lateral  aspect  of  the  cervix,  where  the  tear  runs  in  a  longitudinal 
direction  and  may  extend  into  the  body  or  into  the  vagina.  Often  a 
longitudinal  tear  is  combined  with  a  transverse,  and  complete  and 
incomplete  tears  may  be  combined.  The  edges  of  the  tear  are  thin, 
jagged,  and  infiltrated  with  blood. 

When  the  tear  is  produced  as  just  described,  it  is  called  a 
spontaneous  rupture,  in  contradistinction  from  an  artificial  rupture, 
which  is  directly  referable  to  the  interference  of  the  obstetrician.  If, 
for  instance,  the  passive  portion  of  the  uterus  is  distended  to  its 
utmost  limit,  and  the  accoucheur  tries  to  introduce  his  hand  in  order 
to  perform  version,  the  canal  must  rupture.  Or,  if  there  is  room 
enough  for  his  hand  to  seize  a  foot,  the  movement  imparted  to  the 
foetus,  especially  the  head,  may  result  in  the  rupture  of  the  uterus. 
Sometimes  the  distention  is  much  more  marked  on  one  side  than  on 
the  other.  In  cross  presentation  this  will  be  the  side  in  which  the 
head  lies,  and  in  head  presentations  in  a  flat  pelvis  the  occiput  is 
liable  to  slide  to  a  side,  and  this  portion  is  then  in  greatest  danger  of 


528 


ABNORMAL    LABOR. 


being  ruptured.  With  a  pendulous  abdomen  it  is  the  posterior  wall 
that  is  most  exposed.  Lateral  obliquity  of  the  uterus  drives  the 
presenting  part  over  to  the  side  opposite  to  that  in  which  the  fundus 
lies.  Such  partial  distention  imparts  a  slanting  direction  to  the  con- 
traction ring,  which  is  pushed  down  on  the  menaced  side.  The  cor- 
responding round  ligament  is  also  stretched  and  forms  a  tense  ridge 
even  during  the  interval  between  labor-pains. 

Symptoms. — If  the  obstetrician  follows  the  rules  laid  down  in  dif- 
ferent parts  of  this  work,  neither  a  contracted  pelvis,  nor  a  cross 

Fig.  393. 


Rupture  of  the  anterior  wall  of  the  cervix  uteri.     (Wood's  Museum,  Bellevue  Hospital,  No.  li:;9.) 
One-third  actual  size,    a,  contraction  ring ;  b,  rapture ;  c  c,  external  os. 

presentation,  nor  a  hydrocephalic  head  can  escape  his  attention  ;  but 
if  nothing  else  has  told  him  so,  the  mere  fact  that  labor  does  not  pro- 
gress should  impel  him  to  make  a  thorough  examination,  when  he  in 
all  probability  will  find  the  cause.  Sometimes  the  general  condition 
of  the  patient  may  contain  a  hint  of  impending  danger  of  rupture. 
She  may  complain  of  pain  even  in  the  interval  between  contractions. 
She  may  be  anxious  and  restless.     Her  pulse  may  be  small,  hard, 


RUPTURE    OF   ORGANS.  529 

and  rapid.  There  may  be  a  little  rise  in  temperature.  A  mere 
glance  at  the  abdomen  may  reveal  the  high  position  of  the  contrac- 
tion ring, — on  the  level  of  the  umbilicus,  or  even  above.  The  broad- 
ness of  the  abdomen  may  indicate  the  presence  of  a  transverse  pres- 
entation. The  large  hydrocephalic  head  may  be  felt  through  both 
the  vagina  and  the  abdominal  wall.  The  faulty  presentation  of  the 
foetus  is  at  once  ascertained  by  abdominal  palpation.  The  narrow- 
ness of  the  pelvis  is  found  by  means  of  pelvimetry. 

When  the  rupture  actually  takes  place,  the  patient  may  feel  a 
severe  abdominal  pain,  and  the  tearing  of  the  tissues  may  even  be 
accorfipanied  by  a  sound  audible  to  bystanders. 

Unless  there  is  impaction,  the  presenting  part  recedes  and  is  no 
longer  within  reach,  or  it  has  been  supplanted  by  another  part  of  the 
fetal  body.  Labor-pains  cease  at  once.  Blood  flows  from  the  genital 
canal.  The  place  where  the  rupture  has  occurred  becomes  sensitive 
to  pressure.  The  usual  signs  of  loss  of  blood — coldness  and  clam- 
miness of  the  skin,  pallor,  dyspnoea,  faintness,  syncope,  pulselessness 
— may  develop.  Sometimes  the  patient  vomits.  The  foetus  may  be 
felt  through  the  abdominal  wall  lying  in  the  abdominal  cavity,  side 
by  side  with  the  contracted  uterus.  By  vaginal  examination  the  tear 
itself  can  be  felt ;  and  sometimes  knuckles  of  the  intestine  may  pro- 
lapse through  it.  If  the  rupture  is  extraperitoneal,  two  other  symp- 
toms may  develop.  One  is  subcutaneous  emphysema,  which  is 
recognizable  by  the  sensation  of  air-bubbles  moving  under  the  fingers 
in  palpating  the  abdomen,  and  by  a  peculiar  crepitant  sound  heard 
when  the  skin  is  being  palpated.  This  phenomenon  is  due  to  the 
entrance  of  atmospheric  air  into  the  subcutaneous  connective  tissue. 
The  other  is  the  formation  of  a  haematoma  under  the  pelvic  peri- 
toneum. 

Diagnosis. — The  diagnosis  may  not  be  easy,  all  symptoms  being 
little  marked  or  absent,  and  the  child  may  even  be  born  per  vias 
naturales.  It  is  particularly  the  incomplete  rupture  that  may  be  diffi- 
cult to  recognize ;  and  if  there  is  one,  it  may  be  mistaken  for  a  com- 
plete rupture,  the  intestinal  knuckles  being  felt  so  plainly  through  the 
thin  peritoneum  that  they  may  seem  to  be  in  direct  contact  with  the 
examining  fingers.  The  chief  diagnostic  symptoms  are  the  sudden, 
severe  pain  in  the  abdomen,  the  hemorrhage  from  the  genital  canal, 
the  arrest  of  labor-pains,  the  retrocession  of  the  presenting  part,  the 
palpation  of  the  tear  itself,  and  of  the  foetus  in  the  abdominal  cavity 
outside  the  uterus. 

When  the  rupture  occurs  during  the  performance  of  version,  it  is 
accompanied  by  hemorrhage,  and  the  operation  all  of  a  sudden  be- 
comes easy. 

Frognosis. — For  the  foetus  the  prognosis  is  almost  absolutely  bad. 

84 


530  ABNORMAL   LABOR. 

It  bleeds  to  death  or  it  becomes  asphyxiated  by  the  detachment  of  the 
placenta.  Among  the  mothers  there  is  also  a  great  mortality.  Still,  one 
out  of  six  is  said  to  recover.  Some  die  promptly  from  hemorrhage 
or  nervous  shock,  and  the  others  a  few  days  later  from  peritonitis. 

Treatment. — There  is  a  large  scope  for  prophylaxis,  as  evinced 
by  the  fact  that  the  lesion  is  much  rarer  in  hospitals  and  in  the  hands 
of  experienced  obstetricians  than  in  private  practice,  especially  that  of 
mid  wives.  For  a  practised  eye  the  high  position  of  the  contraction 
ring  is  an  unmistakable  warning  of  the  impending  danger.  The  only 
condition  at  all  like  it  may  be  produced  by  a  full  bladder,  and  in  this 
respect  all  doubt  is  dispelled  by  the  use  of  the  catheter.  Another 
characteristic  point  is  the  tension  of  the  round  ligament,  which  con- 
tinues in  the  interval  between  contractions.  Careful  examination 
should  be  made  both  during  contractions  and  in  the  interval,  which 
will  enable  us  to  distinguish  the  thick,  contracted,  active  part  of  the 
uterus  from  the  thin,  chlated  lower  portion. 

When  there  is  much  tension  of  the  cervix  and  the  lower  uterine 
segment,  version  is  contraindicated,  and,  if  at  all  attempted,  the  oper- 
ation should  be  interrupted  during  uterine  contraction. 

Postural  treatment  is  of  great  importance.  When  rupture  threat- 
ens on  one  side,  the  patient  should  be  placed  on  this  side,  whereby 
the  fundus  sinks  down  on  the  couch  and  the  lower  part  of  the  uterus 
rises  in  the  opposite  direction.  A  pendulous  abdomen  should  be  held 
in  place  by  a  binder.  The  elevated-pelvis  position,  facilitating  version 
in  a  high  degree,  wiU  probably  prove  of  great  value  as  a  prophylactic 
of  uterine  rupture,  and  render  the  operation  possible  under  circum- 
stances in  which  heretofore  it  was  impracticable. 

The  labor  should  be  finished  as  soon  as  possible.  Since  the  foetus 
is  practically  lost  anyhow,  its  life  should  not  be  considered.  If  the 
head  presents  and  the  foetus  is  alive,  a  cautious  attempt  may  be  made 
to  apply  the  forceps.  If  this  does  not  succeed,  the  head  should  be 
perforated  and  extracted  with  the  cranioclast  or  the  cephalotribe.  If 
the  child  is  dead,  this  is,  of  course,  done  at  once,  and  likewise  if  it  has 
hydrocephalus.  In  neglected  cross  presentation  embryotomy  has  to 
be  performed. 

For  rupture  occurring  during  pregnancy  there  is  only  one  rational 
treatment, — laparotomy,  removal  of  the  foetus  and  ovum,  and  suture 
of  the  tear. 

If  rupture  occurs  during  labor  and  the  foetus  is  partially  in  the 
uterus,  it  should  be  extracted  through  the  genital  canal.  If  the  head 
presents  and  is  partially  engaged,  it  may  be  extracted  with  the  forceps. 
If  this  instrument  cannot  be  applied,  the  head  should  be  perforated 
and  extracted  with  cranioclast.  If  a  foot  can  easily  be  reached,  it 
should  be  seized  and  extraction  made  in  this  way. 


RUPTURE    OF    ORGANS.  531 

After  the  extraction  of  the  child  a  careful  examination  should  be 
made  of  the  tear.  If  it  is  found  to  be  extraperitoneal  and  hemor- 
rhage has  stopped,  it  is  best  only  to  put  in  an  iodoform  gauze  drain. 
It  is  not  safe  to  inject  any  fluid,  as  there  might  be  a  small  communi- 
cation with  the  abdominal  cavity,  or  protecting  clots  be  dislodged  by 
the  stream. 

If  there  is  hemorrhage  from  the  depth  of  the  wound,  it  will  hardly 
be  possible  to  expose  its  source  so  as  to  be  able  to  tie  bleeding  vessels 
or  circumvent  them  with  a  threaded  needle.  We  must  then  rely  on 
tamponade,  which  must  be  tight  enough  to  prevent  hemorrhage,  and 
still  the  tampon  must  not  be  packed  so  hard  as  to  tear  the  peritoneum. 
As  material  only  sterile  gauze  or  iodoform  gauze  should  be  used. 
With  this  internal  tamponade  may  to  advantage  be  combined  external 
pressure,  by  surrounding  the  uterus  with  large  pads  held  in  place  with 
a  tight  binder,  from  which  two  tails  are  carried  from  behind,  crossed 
over  the  vulva,  and  pinned  in  front. 

If  the  peritoneum  has  been  torn  and  the  foetus  lies  in  the  abdominal 
cavity,  laparotomy  should  be  performed,  the  foetus  removed  through 
the  incision,  and  the  peritoneal  cavity  cleaned  of  clots  and  meconium. 
What  more  should  be  done  depends  on  what  we  find.  If  there  are 
no  indications  of  infection,  it  is  best  to  stitch  up  the  wound  with 
deep  and  superficial  sutures  and  close  the  abdomen.  If,  on  the  other 
hand,  there  are  distinct  symptoms  of  infection — if  the  patient  has  fever 
or  there  are  signs  of  putrefaction — the  uterus  and  appendages  should 
be  removed.  If  the  tear  does  not  extend  below  the  internal  os,  it 
is  enough  to  perform  supravaginal  amputation,^  with  retroperitoneal 
treatment  of  the  pedicle.  Simply  to  surround  the  cervix  and  broad 
ligaments  with  an  elastic  ligature,  cut  off  the  uterus  and  appendages, 
and  treat  the  stump  by  the  extraperitoneal  method  ^ — Porro^s  opera- 
tion— is  less  good,  on  account  of  the  long  after-treatment  and  the  dan- 
ger of  consecutive  ventral  hernia.  If  the  lower  end  of  the  rupture 
cannot  be  reached  by  supravaginal  amputation,  it  is  better  to  perform 
total  hysterectomy.^ 

The  placenta  should  be  removed  from  wherever  it  is  found.  If 
it  is  in  the  uterus,  it  may,  perhaps,  be  expressed  in  the  usual  way. 
If  not,  it  is  detached  by  the  vaginal  route.  *  If  it  is  in  an  extraperi- 
toneal cavity,  we  follow  the  cord  till  we  reach  the  placenta  and  remove 
it  through  the  tear.  If,  finally,  it  lies  in  the  abdominal  cavity,  we 
remove  it  through  the  abdominal  incision. 

The  above  rules  apply  to  lying-in  hospitals  and  private  practice  in 
so  far  as  it  is  feasible  to  follow  them.  But  suppose  the  physician 
stands  alone  in  a  farm-house  or  a  tenement-house.    What  can  he 

1  Garrigues,  Diseases  of  Women,  third  ed.,  p.  518. 
^  Ibid.,  p.  519.  Mbid.,  p.  521. 


532 


ABNORMAL   LABOR. 


Fig.  394. 


do  then  ?  He  can  do  a  great  deal,  and  he  ought  to  do  it.  To  leave 
the  patient  is  almost  to  doom  her  to  sure  death,  which  he  should  so 
much  less  think  of  as  perhaps  he  is  not  without  blame  for  the  de- 
plorable condition  in  which  the  patient  is  situated.  Under  all  circum- 
stances the  accoucheur  should  remove  the  foetus  and  the  placenta 
by  the  genitals,  which  often  has  proved  to  be  an  easy  matter.  Sec- 
ondly, if  there  is  any  hemorrhage  he  should  put  in  a  tampon.  If 
the  intestine  is  prolapsed,  he  should  replace  it  and  keep  it  up  ^^ith 
iodoform  gauze  on  the  top  of  his  tampon.  If  ice  is  available,  it  is 
well  to  place  an  ice-bag  over  the  symphysis.  On  the  third  day,  all 
danger  of  hemorrhage  being  passed,  he  may  remove  the  tampon 
and  replace  it  by  a  gauze  drain.  After  four  or  five  days  he  may  wash 
out  the  cavity  with  plain  water,  and  still  later  with  antiseptic  fluid. 
By  a  treatment  conducted  on  such  lines  many  women  have  recov- 
ered. 

After  the  special  indications  offered  by  the  rupture  have  been 
filled,  and  partly  even  while  they  are  being  attended  to,  attention 
should  be  paid  to  the  general  condition  of  the  patient,  as  detailed 
above  in  speaking  of  hemorrhage. 

§  2.  Pressure  Necrosis  of  the  Uterus  or  Vagina. — When  the 

uterus  or  the  vagina  is  exposed 
to  protracted  pressure  on  a  lim- 
ited area,  the  compressed  tissue 
becomes  mortified  and  is  ex- 
pelled, leaving  a  circular  open- 
ing or  loss  of  substance  (Fig. 
394). 

The  necrosis  may  go  through 
the  whole  thickness  of  the  wall, 
resulting  in  a  communication  be- 
tween the  parturient  cana  land 
the  pouch  of  Douglas  or  the 
bladder,  or  it  may  be  more  su- 
perficial, non-penetrating. 

The  most  common  seat  of 
the  necrosis  is  in  the  posterior 
wall  of  the  cervix,  near  the 
median  line,  where  it  is  pro- 
duced by  pressure  against  the 
promontory.  Next  in  frequency 
it  is  found  on  the  anterior  wall 
of  the  cervix  or  of  the  vagina, 
in  which  locality  it  is  due  to  pressure  against  the  symphysis  pubis. 
More  rarely  the  necrosis  is  produced  by  pressure  against  osteomas, 


Pressure  necrosis  of  uterus.  (Winckel.)  a,  per- 
foration of  cervix  ;  b,  laceration  of  cer%ix  ;  c  c,  tears 
in  the  vagina  ;  d,  contraction  ring;  c,  external  os. 


RUPTURE    OF   ORGANS.  533 

sharp  lines,  or  thorns  on  the  pelvic  wall.  It  may  also  be  due  to  the 
pressure  exercised  by  instruments  used  in  obstetric  operations,  es- 
pecially the   forceps,  the  cranioclast,  or  the  cephalotribe. 

When  the  partition  between  the  cervix  and  the  pouch  of  Douglas 
is  perforated,  the  lochia]  discharge  may  flow  into  the  peritoneal  cavity 
and  give  rise  to  septic  peritonitis.  In  more  favorable  cases  an  adhe- 
sive peritonitis  surrounds  the  opening  and  prevents  communication 
with  the  abdominal  cavity.  The  uterus  then  remains  adherent  to  the 
promontory,  and  the  adhesion  has  even  been  observed  to  become 
ossified  so  as  to  form  a  kind  of  thorn.  Sometimes  a  rectovaginal 
fistula  is  formed. 

A  perforation  in  the  anterior  partition  leads  to  the  formation  of  a 
vesicovaginal  fistula,  or  more  rarely  a  vesicocervical  fistula,  conditions 
entailing  the  constant  dribbling  away  of  the  urine  through  the  vagina, 
which  deplorable  infirmity  was  practically  incurable  until  the  genius 
of  Marion  Sims  taught  the  surgeons  how  to  remedy  it. 

Diagnosis. — The  diagnosis  may  be  quite  difficult,  unless  a  urinary 
fistula  is  established,  when  it  is  only  too  evident.  The  tediousness 
of  the  labor,  followed  by  signs  of  puerperal  infection,  may  make  the 
obstetrician  surmise  the  presence  of  a  perforation.  Upon  vaginal 
examination  with  finger  and  speculum  he  may  be  able  to  feel  the 
opening,  if  it  is  large  enough,  or  to  see  it  through  the  speculum.  A 
small  urinary  fistula  may  be  made  visible  by  injecting  a  little  luke- 
warm milk  into  the  bladder.  An  opening  communicating  with  the 
abdominal  cavity  may  not  be  found  until  it  is  revealed  in  the  autopsy- 
room. 

Prognosis. — The  prognosis  for  the  mother  is  better  than  in  rupture 
of  the  uterus,  and  for  the  child  there  is  little  danger. 

Treatment — The  treatment  is  chiefly  prophylactic.  The  forma- 
tion of  the  perforation  should  be  prevented  by  giving  an  enema  before 
delivery,  by  the  use  of  the  cathether,  and  by  timely  obstetrical  opera- 
tions. In  cases  of  communication  with  the  abdominal  cavity,  all  we 
can  do  is  to  use  mild  antiseptic  vaginal  injections — plain  water,  bo- 
racic  acid,  or  Thiersch's  solution — and  treat  the  peritonitis.  A  small 
fecal  or  urinary  fistula  may  be  made  to  heal  by  keeping  the  parts  as 
clean  as  possible,  insuring  easy  movements  of  the  bowels,  and  pre- 
venting the  urine  from  becoming  alkaline  by  the  administration  of 
benzoate  of  lithium,  ammonium,  or  sodium  (gr.  v  to  xxx — from  30 
centigrammes  to  2  grammes — t.  i.  d.),  acidum  nitricum  dilutum  (nLviii), 
or  Horsford's  acid  phosphates  (a  teaspoonful  in  a  wineglassful  of 
water)  three  times  a  day.  A  large  fistula  will  remain  open  and  require 
a  gynaecological  operation  when  the  time  of  involution  is  passed, — 
say,  in  two  or  three  months  after  confinement.^ 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  385  et  seq. 


534  ABNORMAL   LABOR. 

§  3.  Laceration  of  the  Cervix  Uteri. ^ — Small  tears  in  the  cir- 
cumference of  the  OS  expanded  to  its  utmost  capacity  during  the  pas- 
sage of  the  head  of  the  foetus  are  so  common  that  they  may  be  looked 
upon  as  an  inherent  part  of  childbirth  ;  but  in  other  cases  these  lacer- 
ations acquire  such  dimensions  that  they  constitute  a  more  or  less 
serious  injury,  which  may  offer  immediate  danger  and  lead  to  later 
invalidism. 

By  far  most  commonly  the  tears  follow  the  direction  of  a  radius  of 
the  OS  so  as  to  form  a  A-shaped  solution  of  continuity  in  the  cervi- 
cal portion  of  the  uterus.  They  may  be  complete — that  is  to  say,  go 
through  the  whole  thickness  of  the  cervix — or  incomplete^  when  the 
tear  in  the  cervical  canal  does  not  reach  the  mucous  membrane  of  the 
vagina.  There  may  be  one,  two,  or  more  tears.  The  one  most 
frequently  observed  is  the  bilateral.,  and  next  to  that  the  unilateral, 
which  is  more  frequent  on  the  left  than  on  the  right  side,  a  differ- 
ence which  doubtless  is  due  to  the  preponderance  of  the  left  occipito- 
anterior position  of  the  foetus.  Tears  in  the  anterior  or  posterior 
lip  alone  are  rarer.  The  laceration  may  also  be  stellate.,  which  is  pro- 
duced by  at  least  three  tears  forming  a  star-like  figure.  The  tear 
extends  often  more  or  less  beyond  the  vaginal  junction  and  enters 
the  parametrium  or  the  connective  tissue  behind  the  uterus,  or  it 
implicates  the  bladder.  Much  more  rarely  the  tear  is  transverse.  If 
then  it  is  combined  with  a  radial  tear  the  two  together  form  an  F,  or 
the  end  of  the  anterior  or  posterior  lip  of  the  cervix  may  be  torn  off 
or  even  the  whole  cervical  portion  be  thrown  off  as  a  ring-shaped  body. 

These  tears  are  particularly  apt  to  occur  in  old  primiparae,  in 
whom  the  tissue  has  lost  its  normal  elasticity.  They  are  often  pro- 
duced when  for  some  reason  or  other  it  becomes  necessary  to  extract 
the  foetus  before  full  dilatation  has  been  obtained,  or  in  the  endeavors 
to  establish  this  dilatation. 

Most  of  these  lacerations  heal  either  by  first  or  second  intention, 
and  do  not  give  rise  to  any  immediate  or  remote  trouble ;  but  in 
some  cases  they  become  more  or  less  serious  complications  of  child- 
birth. Deeper  tears  may  cause  serious  hemorrhage  when  the  com- 
pression exercised  by  the  presenting  part  ceases  after  the  birth  of  the 
child.  The  extension  of  the  tear  into  the  loose  tissue  of  the  para- 
metrium may  lead  to  puerperal  infection  and  death.  The  implica- 
tion of  the  bladder  may  result  in  a  vesicovaginal  or  vesico-uterine  fis- 
tula. Frequently  the  laceration  of  the  cervix  is  followed  by  chronic 
inflammation  of  the  neck  and  body  of  the  uterus.^ 

^  Garrigues,  "Laceration  of  the  Cervix  Uteri,"  Archives  of  Medicine,  vol.  vi., 
No.  2,  October,  1881;  "The  Immediate  Closure  of  Laceration  of  the  Cervix," 
Amer.  Jour.  Obstet. ,  vol.  xxiv. ,  No.  11,  1891. 

^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  416. 


RUPTURE   OF    ORGANS.  535 

Treatment. — Since  most  cervical  lacerations  heal  by  nature's  sole 
efforts,  they  do  not  call  for  any  immediate  treatment  unless  they  give 
rise  to  hemorrhage.  Otherwise  we  would  without  necessity  expose 
the  patient  to  infection  during  the  primary  operation. 

The  presumptive  diagnosis  of  the  cervix  being  the  seat  of  the 
hemorrhage  is  made  by  exclusion.  If  the  uterus  is  well  contracted 
we  know  the  source  of  a  post-partum  hemorrhage  cannot  be  the 
body  of  the  uterus,  and  the  vulva  and  part  of  the  vagina  may  be 
directly  inspected.  The  tear  in  the  cervix  may  be  felt,  and  the  cervi- 
cal portion  and  the  upper  part  of  the  vagina  may  be  made  visible  by 
means  of  a  speculum.  Often  it  is  also  possible  to  press  the  uterus  so 
low  down  into  the  pelvis  that  the  cervix  is  brought  into  view  without 
a  speculum. 

The  best  treatment  is  to  unite  the  lips  of  the  tear  by  catgut  suture, 
which  not  only  arrests  the  hemorrhage,  but  also  effects  union  by  the 
first  intention.  Sometimes  a  thorough  tamponade  of  the  vagina,  and, 
if  deemed  necessary,  of  the  uterus  too,  will  master  the  hemorrhage. 

§  4.  Laceration  of  the  Vagina. — Lacerations  of  the  vagina  are 
especially  liable  to  occur  at  the  upper  end,  where  the  vagina  forms  the 
continuation  of  the  cervical  canal,  and  at  the  lower  end,  the  entrance 
to  the  vagina  being  the  narrowest  part  of  the  parturient  canal. 

The  tears  in  the  upper  portion  may  penetrate  into  the  abdominal 
cavity,  and  then  they  become  much  like  similar  ruptures  of  the  uterus. 
The  direction  is  mostly  transverse,  and  the  tear  takes  place  on  the 
anterior  or  the  posterior  wall,  or  it  may  extend  around  the  whole 
circumference,  when  the  vagina  in  toto  separates  from  the  cervix — so- 
called  colpaporrhexis.  The  symptoms,  prognosis,  and  treatment  of 
such  lacerations  are  essentially  the  same  as  when  the  laceration  occurs 
in  the  body  of  the  uterus.  In  regard  to  diagnosis,  there  is  this  differ- 
ence, that  labor-pains  do  not  cease  so  abruptly  as  in  rupture  of  the 
uterus,  and  that  there  is  less  hemorrhage  and  shock. 

There  may  also  occur  longitudinal  tears  in  the  vagina,  which  may 
be  superficial,  and  then  are  of  comparatively  little  consequence,  or 
extend  through  the  whole  thickness  into  the  perivaginal  connective 
tissue,  when  they  may  give  rise  to  considerable  hemorrhage  and  open 
the  way  for  wide-spread  puerperal  inflammation. 

At  the  entrance  to  the  vagina  longitudinal  tears  are  very  common, 
especially  on  the  posterior  circumference,  near  the  median  line.  In 
primiparge  they  may  almost  be  looked  upon  as  belonging  to  normal 
childbirth,  but  they  may  also  be  found  in  women  who  have  borne 
children  before.  By  introducing  a  finger  into  the  rectum  and  press- 
ing forward,  this  laceration  is  seen  as  a  rhomboid  figure,  with  narrower 
angles  above  and  below  and  wider  ones  towards  the  sides. 

In  the  lower  part  of  the  vagina  tears  often  occur  in  connection 


536  ABNORMAL   LABOR. 

with  those  of  the  perineum,  which  presently  wih  be  considered.  In 
exceedingly  rare  cases  the  tear  occurred  in  the  rectovaginal  septum 
and  the  child  was  born  per  rectum. 

Treatment. — Superficial  tears  in  the  vagina  hardly  call  for  any 
treatment  beyond  the  common  prophylaxis  we  have  recommended 
for  all  labor  cases.  They  will  either  unite  by  mere  apposition  of  the 
edges  or  suppurate,  when  the  wound  secretion  will  mix  with  the 
lochial  discharge  coming  from  the  uterus.  Deep  lacerations  should 
be  closed  by  sutures,  either  running  or  interrupted.  If  the  necessary 
instruments,  materials,  and  assistance  are  not  present  and  there  is 
bleeding,  recourse  must  be  had  to  styptic  applications  or  tamponade. 
In  a  case  of  birth  through  the  rectum,  a  double  row  of  sutures  should 
be  applied — one  in  the  rectum,  another  in  the  vagina. 

Protracted  pressure  against  limited  points  of  the  vagina  may  lead 
to  subsequent  necrosis.  If  the  anterior  wall  is  compressed  between 
the  fetal  head  and  the  symphysis  pubis,  the  result  may  be  the  for- 
mation of  a  vesicovaginal  fistula.  In  order  to  prevent  this  serious 
injury,  the  prolonged  pressure  should  be  avoided  by  timely  use  of 
the  forceps.  Instruments  are,  however,  apt  to  cause  injury  them- 
selves, and  should,  therefore,  be  applied  deliberately,  cautiously,  and 
skilfully,  bearing  in  mind  that  in  most  cases  the  safe  delivery  is  much 
more  a  question  of  gentleness  and  dexterity  than  of  brutal  mechanical 
force. 

§  5.  Laceration  of  the  Vulva  and  Perineum. — Towards  the  end 
of  parturition  the  perineum  becomes  enormously  distended,  elongated^ 
and  thinned,  and,  since  the  normal  tissue,  even  outside  of  childbirth, 
ends  with  the  thin,  sharp  edge  formed  by  the  fourchette,  some  degree 
of  tear  at  this  point  is  exceedmgly  common.^ 

The  parturient  canal  is,  near  and  at  its  end,  limited  by  two  com- 
paratively narrow  openings, — the  entrance  to  the  vagina  and  the  rima 
pudendi, — the  first  of  which  is  circular  from  the  beginning,  while  the 
second  becomes  so  when  distended  by  the  foetus  being  pushed  through 
it.  Of  these  rings  the  inner  one  is  again  the  narrower,  but  formed 
by  stronger  muscular  and  sinewy  tissue  than  the  outer,  which  is  only 
composed  of  the  skin  and  subcutaneous  fat.  These  two  rings  are  the 
seats  where  laceration  commonly  begins  during  childbirth,  and  from 
which  it  may  extend  more  or  less  into  the  neighboring  tissues.  The 
inner  ring,  being  the  narrower  of  the  two,  suffers  more  constantly,  but 
a  superficial  tear  here,  even  if  it  extends  far  up  into  the  vagina,  is  of 
little  importance.  A  deep  tear  of  this  ring,  involving  the  levator  ani 
muscle  with  its  two  fasciae,  is,  on  the  contrary,  a  fruitful  source  of 

^  Garrigues,  "The  Obstetric  Treatment  of  the  Perineum,"  Amer.  Jour.  Obst., 
vol.  xiii.,  No.  2,  April,  1880;  "So-called  Laceration  of  the  Perineum,"  MedicaL 
News,  April  25,  1891. 


RUPTURE    OF    ORGANS. 


537 


future  suffering.  The  tear  in  the  levator  ani  muscle  is  usually  found 
backward  and  outward  in  the  direction  of  the  tuberosity  of  the 
ischium,  probably  because  the  muscle  gets  caught  between  this  point 
and  the  head,  while  in  the  median  line  the  rectum  furnishes  a  soft 
pad  between  the  vagina  and  the  levator  ani  muscle.  The  tear  is 
much  more  common  on  the  right  than  on  the   left  side,  which  is 

Fig.  395. 


Laceration  of  the  perineum  and  vagina. 

presumably  due  to  the  preponderance  of  the  left  occipito-anterior  posi- 
tion, the  occiput  escaping  from  the  parturient  canal,  while  the  broad 
forehead  is  pressed  against  the  posterior  wall  of  the  vagina. 

The  external  ring,  formed  by  the  expanded  rima  pudendi,  often 
escapes  all  injury  through  childbirth,  so  that  even  the  thin  edge  of  the 
fourchette  may  be  found  entire  in  women  who  have  borne  children. 
It  may,  however,  suffer  in  different  places.     The  most  common  is  a 


538 


ABNORMAL   LABOR. 


tear  in  the  median  line,  beginning  at  the  posterior  commissure,  from 
which  it  may  extend  down  to  and  into  the  rectum  and  up  to  or 
through  the  entrance  to  the  vagina.  In  the  minor  degrees  the  torn 
surface  has  the  shape  of  a  double  triangle,  the  two  halves  being  con- 
tiguous in  the  depth  of  the  wound  (Fig.  395).  When  the  tear  does 
not  break  the  anal  ring,  it  is  called  an  incomplete  laceration  of  the 
perineum ;  when  it  extends  into  the  rectum,  it  is  called  a  complete 
laceration. 

More  rarely  the  laceration  begins  in  the  centre  of  the  perineum 
(Fig.  396)  and  extends  into  the  vulva,  forming  a  similar  tear,  as  if  it 
had  started  from  the  fourchette.     Sometimes  the  more  elastic  skin 

Fig.  396. 


Central  laceration  of  the  perineum.     (Ribemont-Dessaignes.) 


resists,  while  the  muscular  and  fascial  tissues  are  severed.  In  rare 
cases  the  reverse  may  take  place,  the  skin  bursting,  while  the  deeper 
parts  stand  the  dilatation  uninjured.  In  the  rarest  cases  the  tear  in 
the  perineum  becomes  sufficiently  large  to  admit  the  passage  of  the 
foetus  through  it  without  implicating  the  rima  pudendi  or  the  anus, — a 
so-called  central  laceration  (Fig.  396). 

If  the  perineum  escapes  or  suffers  little,  the  injury  often  takes  the 
shape  of  superficial  tears  on  the  labia  majora  or  deeper  ones  in  the 
labia  minora  and  vestibule  near  the  clitoris,  which  may  give  rise  to 
dangerous  or  even  fatal  hemorrhage. 


RUPTURE    OF   ORGANS.  539 

Nearly  all  tears  being  due  to  circular  expansion,  the  parts  ordi- 
narily separate  from  side  to  side,  and  the  rents  have  a  longitudinal 
direction,  more  or  less  parallel  to  the  axis  of  the  parturient  canal ; 
but  if  the  severed  halves  of  the  perineum  do  not  unite  by  primary 
intention,  they  heal  separately,  each  forming  one-half  of  a  cicatrice,  in 
v^rhich  way  cicatrices  with  a  transverese  direction  are  formed. 

Sometimes  nature  can  effect  complete  agglutination  and  coales- 
cence by  first  intention  of  any  tear,  complete  or  incomplete.  But 
such  a  process  is  of  so  extremely  rare  occurrence  that  it  would  be 
foolhardiness  to  expect  it.  In  the  great  majority  of  cases  the  spon- 
taneous healing  is  altogether  insufficient.  An  incomplete  tear  in  the 
median  line  will  grow  a  little  together  by  granulation  at  the  top  of  the 
angle.  The  remainder  will  only  heal  over  and  form  a  contracted 
transverse  scar.  A  complete  tear  will  leave  the  anal  ring  broken  : 
the  sphincter  retracts,  its  ends  being  plainly  marked  by  a  little  pit  of 
the  size  of  a  large  pea  on  either  side.  Where  the  perineal  body 
should  be  there  is  a  A-shaped  cleft.  The  mucous  membrane  of  the 
rectum  rolls  out,  forming  a  little  red,  soft,  puckered  protrusion  at  the 
posterior  circumference  of  the  anal  opening.  The  patient  has  no  con- 
trol over  flatus  and  faeces,  which  escape  involuntarily,  and  make  the 
poor  woman  a  subject  of  disgust  to  herself  and  others. 

A  tear  involving  the  levator  ani  muscle  and  the  sinewy  structures 
of  the  entrance  to  the  vagina  weakens  the  support  of  the  pelvic 
structures  situated  above.  As  soon  as  the  patient  gets  up  from  child- 
bed, she  complains  of  a  disagreeable  feeling  of  looseness  and  bearing- 
down,  and  in  the  course  of  time  a  complete  prolapse  of  the  uterus 
and  inversion  of  the  vagina  may  be  the  result. 

Etiology. — The  obstetric  canal  forms  a  curved  cylinder  (Fig.  195, 
p.  155).  The  propelling  force  acts  from  above  almost  under  right 
angles  to  the  plane  of  the  brim  of  the  pelvis.  When  the  os  coccygis 
is  reached,  this  movable  organ  is  bent  backward  and  straightened  out. 
The  perineum  is  much  elongated,  so  that  the  distance  from  the  anus 
to  the  vulva  may  measure  five  or  six  inches  (13-15  centimetres).  No 
wonder,  then,  that  this  thin,  weak  structure  is  apt  to  give  way  under 
the  pressure  that  is  exercised  on  it.  Besides  this  general  danger  to 
which  every  perineum  is  exposed  during  childbirth,  there  are  particu- 
lar unfavorable  circumstances  that  jeopardize  its  integrity.  Thus,  the 
vagina  and  vulva  may  be  too  small  or  the  foetus  too  large,  or  the  tis- 
sue is  not  elastic  enough,  as  is  especially  the  case  in  very  young  or  old 
primiparae.  The  pelvic  inclination  may  be  too  small,  the  sacrum  too 
straight,  or  the  pubic  arch  too  narrow.  The  perineum  may  be  too 
long  and  the  perineal  body  too  thin.  Gildema,  varices,  condylomas, 
vegetations,  ulcerations,  and  scars,  all  predispose  to  laceration.  Cross 
or  brow  presentation,  occipitoposterior  position,  or  the  prolapse  of  an 


540  ABNORMAL  LABOR. 

arm  beside  the  head  endangers  the  perineum.  A  precipitate  labor, 
in  which  the  parts  do  not  have  time  to  become  softened  and  expand 
graduahy,  is  a  frequent  cause  of  laceration  of  the  perineum.  The  same 
applies  to  forceps  operations  and  manual  extraction  when  performed 
too  rapidly.  The  forceps  may  also  injure  the  perineal  body  directly, 
the  shanks  being  pressed  or  rubbed  against  it. 

It  is  hard  to  ascertain  the  frequency  with  which  the  perineum  is 
torn,  but  in  general  we  may  say  that  even  with  good  treatment  it 
happens  in  about  25  per  cent,  of  primiparas  and  5  per  cent,  of  pluri- 
parae.  Its  occurrence  is  by  no  means  always  the  fault  of  the  accou- 
cheur. He  has  therefore  no  occasion  to  be  ashamed  of  it  or  try  to 
conceal  it. 

Prophylaxis. — Much  may  be  done  to  prevent  or  limit  a  laceration 
of  the  perineum.  Since  it  is  a  chief  point  in  this  respect  that  the 
lower  part  of  the  obstetric  canal  shall  have  time  to  become  softened 
and  dilated,  ergot  ought  never  to  be  given  during  labor. 

The  bowels  should  be  emptied  with  a  soapsuds  enema  before  the 
passage  of  the  foetus.  The  position  on  the  left  side  during  delivery  is 
preferable  to  that  on  the  back,  because  in  the  former  the  fundus  uteri 
sinks  down  on  the  bed,  so  that  gravitation  works  in  an  almost 
opposite  direction  to  the  uterine  contractions.  Thus  the  perineum 
has  not,  as  in  the  dorsal  position,  to  carry  the  weight  of  the  foetus  in 
addition  to  the  pressure  against  it  caused  by  the  foetus  being  driven 
down  by  the  expellent  forces. 

If  the  waters  have  broken  long  before  the  birth  of  the  child,  and 
the  vagina  is  dry,  it  is  well  to  pour  creoline  or  lysol  solution  into  it  in 
order  to  make  it  slippery  during  the  alternate  advance  and  retreat  of 
the  presenting  part. 

The  administration  of  chloroform  while  the  foetus  passes  the  vulva 
is  of  high  value  as  a  protection  against  laceration.  Pain  being 
abolished  and  the  abdominal  muscles  paralyzed,  the  child  is  pushed 
forward  by  the  mere  uterine  contractions,  and  even  these  are 
weakened  by  the  effect  of  the  drug. 

The  foetus  forms  a  kind  of  cylindrical  body,  the  vulvar  orifice  an 
elastic  ring.  Now,  it  is  evident  that  this  ring  will  be  stretched  the 
least  when  its  diameter  intersects  the  long  axis  of  the  cylinder  at  right 
angles.  If  this  relation  does  not  exist,  it  may  be  an  advantage  to  dis- 
place the  posterior  part  of  the  ring  forwards  or  backwards,  according 
to  circumstances.  If  the  vulvar  ring  encircles  the  fetal  body  in  this 
favorable  way,  every  displacement  will  only  have  the  effect  of  sub- 
jecting the  ring  to  an  unwarranted  surplus  of  stretching,  and  thereby 
expose  it  to  break. 

Another  kind  of  protection  is  afforded  to  the  perineum  by  acting 
on  the  foetus.     A  too  speedy  expulsion  of  the  foetus  may  be  counter- 


RUPTURE    OF   ORGANS.  541 

acted  by  direct  pressure  with  the  flat  hand  on  the  presenting  part, 
especially  the  cranium.  Jf  the  head  does  not  recede  in  the  intervals 
of  pains,  it  is  well  to  push  it  back,  so  that  the  next  uterine  contrac- 
tion may  be  partly  spent  in  recovering  lost  ground.  In  this  way 
undue  pressure  on  one  point  is  also  avoided.  In  cases  of  manual 
extraction,  the  head  ought  to  be  drawn  as  slowly  as  possible  through 
the  vulvar  orifice.  In  forceps  deliveries  it  is  advisable,  if  the  con- 
dition of  the  mother  or  the  f(ptus  does  not  so  imperatively  call  for  the 
utmost  speed  as  to  supersede  all  other  considerations,  to  take  off  the 
forceps  when  the  head  has  been  brought  into  the  vulvar  orifice  and 
enucleate  the  head  from  the  rectum. 

Often  we  fmd  under  the  ligamentum  arcuatum  a  free  space  which 
may  be  utilized  to  lessen  the  pressure  on  the  perineal  body  by  push- 
ing the  presenting  part  forward.  This  pressure  against  the  present- 
ing part  may  be  practised  directly  on  it,  or  to  overcome  slipperiness 
we  may  cover  the  part  Avith  a  pad,  or  the  pressure  may  be  directed 
through  the  perineum,  or,  what  is  preferable,  through  the  rectum. 
The  patient  lying  on  her  left  side,  the  index  and  middle  finger  of  the 
left  hand  are  introduced  deeply  into  the  rectum  and  pressed  against 
the  forehead  of  the  child.  We  may  even  during  an  interval  of  labor- 
pains  slowly  press  the  head  out  through  the  vulva  by  a  kind  of  enu- 
cleation. The  fingers  in  the  rectum  are  gradually  moved  from 
the  forehead  of  the  child  to  the  upper  maxillary  bones  and  finally 
hooked  under  the  chin.  Certain  precautions  must,  however,  not  be 
neglected  in  using  this  method.  Above  all,  we  must  be  careful  not  to 
injure  the  eyes  of  the  child.  Another  point  of  great  importance  is 
not  to  press  "with  so  much  force  as  to  cause  laceration  in  the  region 
of  the  clitoris  (see  p.  193).  The  proper  time  for  resorting  to  enuclea- 
tion is  when  the  anus  is  pushed  forward  and  distended  and  the  vertex 
during  uterine  contractions  is  propelled  into  the  vulvar  orifice. 

The  perineum  is  threatened  as  much  or  even  more  by  the  passage 
of  the  shoulders  than  by  that  of  the  head,  in  which  respect  the  reader 
is  referred  to  what  has  been  said  in  discussing  the  management  of 
normal  labor  (p.  193). 

If  all  means  hitherto  considered  do  not  seem  sufficient  to  save 
the  perineum,  we  may  still  try  to  do  so  by  the  operation  called 
episiotomy.  An  incision  is  made  in  the  labia  majora,  about  half  an 
inch  from  the  median  line,  in  the  direction  of  the  tuberosity  of  the 
ischium.  It  is  best  made  with  sharp,  blunt-pointed  scissors,  and  if 
performed  during  a  labor-pain,  the  pain  from  the  incisions  is  little 
noticed.  The  operator  should  be  sure  to  cut  behind  the  aperture  of 
the  duct  of  Bartholin's  gland,  so  as  not  to  injure  these  organs  nor 
to  wound  the  vulvovaginal  bulb,  wliich  would  cause  considerable 
hemorrhage.     The  edges  of  the  wounds  should  be  united  by  sutures, 


542  ABNORMAL   LABOR. 

since  otherwise  they  do  not  heal  together,  and  the  vulvar  orifice  is 
likely  to  gape  and  become  triangular.  The  writer  has  practically 
abandoned  this  operation.  It  is  in  most  cases  uncertain  whether  a 
laceration  of  the  perineum  will  occur  or  not  without  episiotomy. 
The  operation  is  no  absolute  protection  against  the  tear.  If  the  cuts 
shall  be  sutured,  we  might  about  as  well  suture  the  torn  perineum, 
which  is  nature's  work,  as  incisions  made  by  ourselves. 

Treatment. — As  soon  as  labor  is  completed,  the  accoucheur  should 
make  an  ocular  examination  of  the  condition  of  the  perineum  by 
separating  the  labia  majora.  In  certain  cases  serres-fines  may  be  used 
to  unite  the  torn  perineum.  These  are  small  wire  clamps  ending  in 
two  or  three  fine  claws  (Fig.  397).  They  are  little  used  nowadays, 
but,  if  well  made,  they  are  quite  useful  in  ap- 
propriate cases.  Tiemann  has  made  some 
c{uite  satisfactory  ones  for  me.  They  are  one 
and  a  half  inches  long,  one-half  of  which  be- 
^^iir::^^:^^^"^""  \_j^'''^^^^  lougs  to  tlie  Icgs  beyoud  the  crossing.  The 
spring  force  should  be  so  w^eak  that  the  ac- 

Serre-fine.  '-         " 

coucheur  can  put  them  on  the  web  between 
his  thumb  and  index-finger  without  feeling  any  pain.  When  the  patient 
is  cleaned  and  lies  on  her  left  side,  the  accoucheur,  standing  behind 
the  patient,  lifts  the  edges  of  the  wound  between  his  left  index-finger 
and  thumb  and  applies  from  one  to  three  serres-fines,  according  to 
the  length  of  the  rent.  The  one  nearest  the  anus  is  applied  first,  at 
about  one-third  to  one-half  inch  (1  centimetre)  in  front  of  the  posterior 
angle  of  the  tear,  the  others  at  a  similar  distance  from  one  another. 
The  foremost  is  put  on  the  edge  of  the  fourchette.  They  are  put  on 
at  right  angles,  and  should  be  pushed  in  as  far  as  they  go.  Before 
placing  them,  the  wound  should  be  cleaned  with  some  antiseptic  solu- 
tion. Very  seldom  it  becomes  necessary  to  tie  or  circumvent  an  artery 
or  cut  ofi"  a  loose  shred  of  tissue.  The  pain  of  their  application  is 
insignificant  and  momentary.  They  remain  in  place  four  days.  Their 
removal  causes  still  less  pain  than  their  insertion.  When  they  have 
been  removed,  the  sides  of  the  rent  appear  lifted  up  in  a  ridge,  which 
subsides  within  a  fortnight.  In  the  places  where  the  claws  have 
pressed  are  seen  minute  ulcerations  which  heal  readily.  A  good 
instrument  never  cuts  through.^ 

While  they  are  in  place,  the  knees  should  be  kept  tied  and  the 
bowels  should  be  kept  open  with  a  mild  aperient.  The  patient  is 
allowed  to  urinate,  if  she  can,  and  to  lie  on  the  back  or  on  either  side, 
as  she  prefers. 

^  Tiemann  keeps  these  little  clamps  under  my  name,  because  I  had  them 
made  differently  from  those  he  used  to  have  and  which  were  very  objectionable. 
The  honor  of  invention  belongs  to  Vidal  de  Cassis,  a  Parisian  surgeon. 


RUPTURE   OF   ORGANS.  543 

It  is  hardly  possible  to  indicate  in  a  theoretical  way  which  cases 
are  fit  for  the  treatment  with  serres-fines.  First  of  all,  I  would 
exclude  all  cases  in  which  the  rent  extends  into  the  anal  canal. 
Next,  cases  in  which  the  rent  is  high,  for  it  is  evident  that  the  clamps 
can  exercise  their  power  but  a  short  distance  beyond  the  surface 
included  within  their  grasp.  Also  cases  where  the  wound  is  inter- 
nal, and  the  perineum  intact.  In  fat  women  with  hard,  unyielding 
tissues,  it  is  impossible  to  raise  the  fold  upon  which  they  should  be 
applied,  or  the  deeper  layers  are  withdrawn  from  the  embrace  of  the 
clamps,  so  that  they  only  take  hold  of  the  skin.  But  after  subtract- 
ing all  these  conditions,  there  remains  a  large  number  of  cases  in 
which  they  may  be  used  to  advantage.  On  account  of  the  trifling 
pain  and  the  great  simplicity  of  their  application,  this  procedure  can 
be  resorted  to  in  all  suitable  cases,  and  it  recommends  itself  especially 
to  the  young  practitioner  who  wishes  to  avoid  too  much  attention 
being  concentrated  on  the  laceration,  and  to  the  busy  practitioner 
who  is  anxiously  awaited  in  other  houses.  By  using  serres-fmes 
many  a  rent  will  be  closed  that  otherwise  would  be  left  unheeded. 

In  cases  tliat  are  not  fit  for  serres-fines,  sutures  should  be  used. 
If  deep  rents  occurring  in  the  perineal  body,  while  the  skin  between 
the  anus  and  the  vulva  remains  intact,  do  not  heal  up,  they  lead  to 
a  membranous  condition  of  the  perineum  which  does  not  give  suf- 
ficient support  to  the  adjacent  parts.  This  kind  of  tears  ought  there- 
fore to  be  sutured  from  the  vagina  and  vulva.  More  commonly  the 
rent  extends  more  or  less  through  the  skin  and  we  find  the  above- 
mentioned  triangles. 

In  uniting  them  by  suture,  we  must  aim  at  an  accurate  adapta- 
tion of  the  edges  and  at  having  as  broad  surfaces  as  possible.  These 
two  desiderata  are  obtained  by  placing  the  sutures  in  a  slanting  way. 
I  mentally  divide  the  two  edges  of  the  triangle  (Fig.  395)  into  three 
parts  of  equal  size.  Silkworm  gut  is  the  best  material,  being  less 
absorbing  than  silk  and  easier  to  insert  and  to  withdraw  than  silver  wire. 
The  patient  is  placed  across  the  bed  with  the  buttocks  at  the  edge. 
The  feet  rest  on  two  chairs,  and  the  knees  are  supported  by  two 
assistants.  The  operator  sits  on  a  third  chair  between  the  two  others. 
Three  rather  large,  curved  needles  are  threaded.  The  patient  is  an- 
aesthetized with  chloroform,  unless  she  is  too  weak.  If  the  doctor  has 
no  skilled  assistant  he  should  ansesthetize  the  patient  himself,  and 
during  the  operation  give  the  necessary  directions  about  keeping  up 
the  anaesthesia.  In  order  to  keep  the  field  of  operation  free  from  dis- 
charge, a  large  tampon  wrung  out  of  antiseptic  fluid  is  pushed  up  into 
the  vagina  above  the  tear.  The  first  needle,  held  in  a  needle-holder, 
is  introduced  a  quarter  of  an  inch  from  the  left  edge  of  the  wound, 
between  the  posterior  and  the  middle  portion  of  the  edge,  and  carried 


544  ABNORMAL    LABOR. 

in  a  curved  line  about  two-thirds  up  to  the  upper  edge  of  the  tear  in 
the  median  hne,  and  then  down  and  out  at  the  corresponding  point  on 
the  right  side.  In  order  to  avoid  including  the  rectum,  the  left  index- 
finger  should  be  inserted  into  it  and  used  for  guiding  the  point  of  the 
needle.  The  finger  should  then  be  washed  off  with  an  antiseptic  solu- 
tion and  the  two  ends  of  the  suture  held  together  with  an  artery- 
forceps  and  dropped.  The  second  needle  is  inserted  between  the 
middle  and  the  anterior  third  of  the  edge  of  the  wound,  at  the  same 
distance  as  before,  and  carried  to  the  point  between  the  inner  and 
the  middle  portion  of  the  upper  edge  of  the  wound.  Here  it  is 
pushed  out  and  carried  over  to  the  corresponding  point  on  the  right 
side,  where  it  is  again  inserted  and  carried  under  the  right  triangle 
and  out  through  the  skin  at  the  point  corresponding  to  the  point  of 
entrance  on  the  left  side.  Finally,  the  third  needle  is  introduced  a 
quarter  of  an  inch  outside  of  the  foremost  end  of  the  tear,  and  carried 
under  the  torn  surface  to  the  point  between  the  outer  and  the  middle 

Fig.  398. 


Transverse  cut  through  knee-bandage. 


portion  of  the  upper  edge  of  the  wound.  Here  it  is  pushed  out, 
carried  over  to  the  corresponding  point  on  the  right  side,  under  the 
right  triangle  and  out  a  quarter  of  an  inch  outside  of  the  upper  end 
of  the  tear. 

Considerable  tissue  should  be  embraced  by  the  sutures,  so  as  to 
avoid  their  cutting  through.  When  all  the  sutures  are  in  place,  the 
tampon  is  withdrawn,  the  surface  is  cleaned,  and  the  sutures  are 
closed  from  behind  forward.     They  are  left  in  place  for  a  week. 

The  knees  are  tied  together  so  as  to  prevent  the  patient  from 
separating  the  thighs  so  much  as  to  exercise  a  strain  on  the  sutures. 
But  for  this  purpose  it  is  by  no  means  necessary  that  the  knees 
should  touch  each  other,  which  is  very  annoying  for  the  patient.  A 
piece  of  muslin  about  six  or  eight  inches  wide  is  carried  around  one 
knee  and  fastened  with  two  safety-pins.  Then  eight  inches  are  left 
free,  and  finally  the  other  knee  is  encircled  in  the  same  way  (Fig.  229, 
4).  A  cut  through  the  bandage  from  side  to  side  would  have  the 
shape  of  a  pair  of  eyeglasses  (Fig.  398).  In  order  to  prevent  the 
knee-bandage  from  sliding  down,  it  is  well  to  fasten  it  to  the  abdomi- 


RUPTURE   OF   ORGANS.  545 

nal  binder  on  each  side  with  a  narrow  piece  of  muslin,  so-called 
suspenders  (Fig.  229,  5,  p.  202).  The  bowels  are  kept  loose  with 
castor  oil  (gii  to  iv — from  8  to  1 5  grammes — daily)  or  Hunyadi  Janos 
water  (siv  to  vi — from  120  to  180  grammes),  and  the  patient  is  mainly 
kept  on  animal  diet  so  as  not  to  have  too  much  residuum  to  be 
exiDelled  through  the  anus. 

As  a  rule,  there  is  not  much  hemorrhage  from  tlie  torn  perineal 
body,  and  it  is  perfectly  arrested  by  the  application  of  the  two  halves 
of  the  wounded  surface  against  each  other.  If  an  artery  is  seen 
spurting,  it  may  be  seized  and  tied  with  thin  catgut,  or  circumvented 
with  thread  and  needle.  Even  if  the  wound  is  somewhat  jagged, 
the  irregularities  in  the  tear  correspond  to  each  other  and  grow  easily 
together.  Only  long,  loose  shreds  with  a  narrow  pedicle  should  be 
cut  off  before  uniting  the  wound.  Instead  of  the  three  silkworm- 
gut  sutures  which  I  recommend,  some  prefer  a  running  suture  with 
catgut. 

If  the  tear  extends  into  the  rectum,  it  is  particularly  advisable  to 
unite  the  torn  surfaces  immediately  after  the  birth  of  the  child.  Even 
if  there  should  remain  a  rectovaginal  fistula,  the  parts  keep  their  shape 
and  remain  in  a  much  better  condition  for  a  future  plastic  operation. 
In  this  case  a  triangular  row  of  sutures  should  be  inserted.  One  row 
is  tied  in  the  rectum.  It  should  be  of  thin  silk,  put  in  rather  super- 
ficially and  left  to  be  expelled  with  the  fseces.  It  is  best  to  attach  a 
needle  to  each  end  of  the  thread  and  push  both  needles  from  the 
wound  to  the  rectum,  so  as  to  avoid  carrj^ing  septic  material  from 
the  gut  into  the  stitch  canals.  A  second  deeper  row  is  put  in  from 
the  vagina  and  tied  there.  For  these  catgut  is  preferable,  which  need 
not  be  removed.  Finally,  a  couple  of  sutures  are  placed  on  the 
skin  surface  of  the-  perineum.  In  this  locality  silkworm  gut  is  the 
best. 

The  primary  perineorrhaphy,  when  the  parts  are  properly  adjusted 
and  antiseptic  precautions  are  taken,  almost  invariably  results  in  heal- 
ing by  first  intention. 

Delayed  Suturing. — If  the  genitals  are  (Edematous,  or  the  patient 
is  much  exhausted,  or  for  some  reason  or  other  the  sutures  cannot 
be  put  in  immediately,  suturing  may  be  put  off  till  the  next  day,  and 
even  much  later, — up  to  the  eleventh  day,  and  perhaps  still  later. 
After  granulation  is  established,  the  wound  may  still  be  united  by 
suture  and  grow  together,  but  then  it  is  best  to  scrape  the  wound 
with  the  edge  of  a  scalpel,  so  as  to  have  fresh  bleeding  surfaces. 

Tears  near  the  Clitoris. — Tears  near  the  clitoris  have  repeatedly 
led  to  a  fatal  issue,  and  ought,  therefore,  to  receive  adequate  attention. 
What  makes  them  so  dangerous  is  that  the  pelvic  veins  all  commu- 
nicate and  have  no  valves.     A  small  wound  may,  therefore,  become 

35 


546  ABNORMAL   LABOR. 

the  source  of  a  hemorrhage  that  may  exhaust  the  vital  force  of  the 
patient.  The  hemorrhage  may,  however,  be  checked  by  passing  a 
ligature  under  the  bleeding  point  and  tying  it  (circumvention)  or  by 
tamponing  the  vulva. 

§  6.  Rupture  of  the  Spleen,  Heart,  Blood-vessels,  and  Psoas 
Muscle. — Several  cases  of  rupture  of  the  spleen  have  been  reported. 
They  occurred  during  pregnancy,  during  labor,  or  shortly  after  the 
same,  and  ended  in  sudden  death.  The  autopsy  showed  the  pres- 
ence of  an  enormous  spleen,  a  rupture  in  the  same,  and  extravasa- 
tion of  a  large  amount  of  blood  into  the  abdominal  cavity.  The 
spleen  was  enlarged  by  malaria,  leucocythsemia,  typhoid  fever,  etc., 
and  gave  way  under  the  impulse  of  a  trauma  or  a  physical  exertion. 

The  ascending  aorta,  the  splenic  artery,  the  epigastric  arter}%  and 
a  large  abdominal  vein  have  ruptured,  either  spontaneously  or  in  con- 
sequence of  an  injury,  and  caused  sudden  death  during  pregnancy  or 
labor. 

In  another  case  the  psoas  muscle  had  ruptured  during  the  efforts 
of  labor. 


CHAPTER    XIV. 

SEPARATION   OF   ARTICULATIONS. 

The  joints  of  the  pelvis  may  rupture  during  the  strain  of  labor. 
That  most  frequently  giving  way  is  the  symphysis  pubis.  The  accident 
is  most  likely  to  take  place  in  pelves  which  are  generally  contracted 
or  narrow  from  side  to  side.  The  common  cause  is  undue  force  in 
forceps  delivery.  Accoucheurs  who  have  more  brawn  than  brain  are 
apt  to  attempt  the  impossible  in  trying  to  drag  by  brutal  force  a  head 
through  a  canal  that  is  proportionally  too  narrow  for  its  passage.  But 
cases  have  also  occurred  in  spontaneous  deliveries,  and  one  case  is 
even  on  record  in  which  the  child  was  born  in  the  membranes  and 
still  the  symphysis  ruptured.  Under  such  circumstances  there  must 
doubtless  have  been  a  previous  weakness  of  the  tissues  composing 
the  joint.  The  writer  has  never  seen  a  case  of  scission  of  the  pubic 
symphysis,  and  in  the  largest  lying-in  institutions  of  Vienna  and  Paris 
this  injury  has  occurred  only  once  in  many  thousand  cases ;  but  it  is 
said  to  be  not  very  rare. 

The  symptoms  are  marked  enough  to  make  a  diagnosis,  even  when 
there  is  no  palpable  diastasis  between  the  ends  of  the  pubic  bones. 
The  patient  feels  severe  pain  in  the  joint,  which  also  is  extremely 
sensitive  to  pressure.  At  the  time  of  the  separation  a  cracking  sound 
may  be  heard.  The  legs  roll  outside.  The  patient  cannot  move 
them,  and  passive  movements  elicit  great  pain.     If  there  is  a  com- 


FRACTURES.  547 

plete  disjunction,  tlie  separation  between  the  bones  is  felt.  Some- 
times the  accident  is  complicated  by  a  tear  in  the  vagina,  through 
which  the  finger  can  be  put  in  direct  contact  with  the  disrupted  joint. 
The  bladder,  the  urethra,  and  the  crus  of  the  clitoris  may  be  torn, 
and  even  without  such  injuries  there  is  commonly  found  dysuria,  such 
as  incontinence,  retention,  or  cystitis. 

With  proper  treatment  the  prognosis  is  good,  but  when  neglected 
the  injury  to  the  joint  is  apt  to  lead  to  suppuration,  which  is  accom- 
panied by  a  high  mortality  through  pyaemia  and  osteomyelitis. 

As  a  rule,  complete  union  is  obtained  in  from  two  to  four  weeks ; 
and  even  if  the  union  is  only  fibrous  the  patient  may  walk,  but  then 
the  gait  is  more  or  less  waddling. 

Treatment. — The  bones  forming  the  articulation  should  be  replaced 
and  kept  immobile  by  broad  straps  of  adhesive  plaster  surrounding 
the  whole  pelvis,  as  after  symphyseotomy.  Complicating  wounds 
should  be  united  by  suture. 

Next  to  the  symphysis  pubis  the  iliosacral  joint  is  the  one  that  is 
exposed  to  rupture.  In  fact,  the  former,  if  the  diastasis  between  the 
bones  becomes  too  great,  leads  to  the  latter,  the  ligaments  in  front  of 
the  articulation  rupturing  under  the  strain  to  which  they  are  put. 

Even  when  this  articulation  does  not  rupture,  the  separation  of 
the  symphysis  allows  a  rotatory  movement  of  the  auricular  surfaces 
against  each  other,  by  which  the  inclination  of  tlie  pelvis  is  increased 
and  the  true  conjugate  lengthened,  conditions  we  shall  come  back  to 
in  speaking  of  labor  in  the  dependent  position  and  the  operation  of 
symphyseotomy. 

The  separation  of  the  sacrococcygeal  joint  has  also  been  observed. 
This  may  become  the  cause  of  a  chronic  inflammation  of  the  articu- 
lation with  coccygodynia.  The  bone  should  be  replaced,  a  lead  and 
opium  wash  applied  outside,  and  suppositories  with  iodoform  (gr.  v 
t.  i.  d.)  used  in  tlie  rectum. 


CHAPTER    XV. 
FRACTURES. 


Fractures  of  bones  in  the  pelvis  or  other  parts  of  the  body  in 
consequence  of  labor  are  rare  accidents.  A  case  has  been  reported 
of  a  double  fracture  of  the  ascending  and  the  descending  ramus  of 
the  pubis.     The  patient  recovered. 

The  fractured  bones  should  be  set  and  the  pelvis  innnobilized  with 
broad  straps  of  adhesive  plaster. 

Somewhat  more  frequently  the  os  coccygis  breaks.  The  articula- 
tion with  the  sacrum  may  be  ankylosed  and  the  fracture  occur  there, 


548  ABNORMAL    LABOR. 

or  it  may  be  found  in  the  bone  itself,  the  vertebrge  of  which  normally 
become  ankylosed  in  the  middle  of  life.  This  little  fracture  may  heal 
in  a  wrong  position  and  become  the  starting-point  of  coccygodynia. 
The  accident  ought  to  be  treated  like  the  rupture  of  the  sacrococcygeal 
joint. 

A  few  cases  of  fracture  of  the  sternum  in  consequence  of  the 
violent  muscular  contractions  during  labor  have  been  placed  on 
record.  The  fracture  is  transverse,  and  mostly  situated  in  the  manu- 
brium. At  the  moment  of  the  accident  the  patient  feels  the  solution 
of  continuity  that  takes  place  and  a  cracking  sound  is  heard.  There 
are  pain  in  the  chest,  mobility  of  the  fragments,  and  crepitus.  There 
is  also  a  change  in  the  shape  of  the  bone,  the  superior  fragment  pro- 
jecting forward,  while  the  inferior  is  depressed.  The  pain  is  much 
increased  by  any  movement  and  by  the  efforts  of  coughing.  Respira- 
tory movements  are  shallow  and  frequent.  The  accident  has  ended 
fatally  in  several  instances. 

The  treatment  consists  in  setting  the  fracture  and  immobilizing  the 
chest  with  a  bandage,  either  plaster  of  Paris  or  a  splint  made  of  felt 
or  wood-pulp.  The  delivery  should  be  terminated  as  soon  as  possible 
according  to  general  rules. 

No  case  of  fracture  of  the  ribs  during  labor  is  known,  but  these 
bones  have  fractured  spontaneously  in  a  few  pregnant  women,  espe- 
cially during  cough.  A  peculiarity  of  these  and  all  other  fractures 
during  gravidity  is  the  slowness  of  the  healing  process,  which,  doubt- 
less, is  due  to  the  phosphate  of  calcium  going  to  build  up  the  skeleton 
of  the  foetus.  It  is,  therefore,  advisable  to  give  phosphorus  internally, 
while  the  fracture  is  treated  in  the  usual  way  with  rest  and  a  bandage. 


CHAPTER   XVI. 

SUDDEN   DEATH   OF   THE   MOTHER. 

During  pregnancy  a  woman  may  be  killed  or  die  more  or  less 
suddenly  in  consequence  of  one  of  the  many  diseases  which  may  com- 
plicate that  condition.  Death  may  also  occur  during  labor  before  the 
child  is  born,  or  during  the  puerperal  state. 

A  distinction  may  be  made  between  a  rapid  death,  where  the  life 
of  the  patient  is  extinguished  in  a  few  hours,  and  a  strictly  sudden 
death,  which  snatches  the  patient  away  almost  instantaneously  and 
without  warning.  A  woman  may  bleed  to  death,  for  instance,  from 
placenta  prsevia,  or  die  in  a  few  minutes  from  post-partum  hem- 
orrhage ;  or  her  nerve  force  may  be  exhausted  by  a  tedious  labor  or 
eclampsia.     Her  uterus  may  rupture,  and  she  may  die  from  the  com- 


SUDDEN   DEATH    OF   THE    MOTHER.  549 

bined  action  of  shock  and  hemorrhage.  In  all  such  cases  the  accou- 
cheur sees  the  gravity  of  the  situation,  he  has  time  to  do  something  to 
avert  the  impending  blow,  and  he  may  even  succeed  in  his  efforts  to 
save  the  patient's  life.  But  there  are  other  cases  in  which  the  patient 
succumbs  as  if  struck  by  lightning, — a  most  terrific  situation  both  for 
the  medical  attendant  and  for  the  friends  of  the  patient.  Some  such 
cases  were  due  to  the  rupture  of  a  cerebral  vein  with  apoplexy.  In 
others  death  was  caused  by  endocarditis,  an  embolus  being  detached 
from  the  heart  and  lodging  in  a  cerebral  artery,  or  by  acute  myo- 
carditis. In  others,  again,  the  sudden  death  was  brought  about  by 
entrance  of  air  into  the  veins. 

Sometimes  the  heart,  previously  diseased,  or  an  aneurism  of  the 
aorta,  or  the  diaphragm  has  ruptured  in  consequence  of  the  efforts 
to  expel  the  foetus.  A  pericardial  exudation  may  paralyze  the  heart. 
The  sudden  diminution  in  the  blood-pressure  within  the  abdominal 
organs  which  takes  place  when  the  foetus  is  expelled  is  accompanied 
by  a  rush  of  blood  to  these  parts  and  a  corresponding  anaemia  of  the 
brain,  which  may  cause  syncope  and  death.  Hence  the  importance  of 
keeping  the  patient  in  the  recumbent  position.  Great  pain,  loss  of 
blood,  and  protracted  labor  may  exhaust  the  patient  and  end  in  sud- 
den death. 

In  some  cases  even  the  autopsy  fails  to  divulge  the  secret  of  the 
cause  of  death.     Nothing  is  found  to  explain  it. 

During  the  puerperal  state  sudden  death  may  be  occasioned  by 
embolism  of  the  pulmonary  artery.  The  offending  body  may  be  torn 
off  from  a  thrombus  during  the  act  of  friction  with  an  ointment,  or  it 
may  be  detached  spontaneously  by  a  movement  of  the  patient,  espe- 
cially in  bending  down  to  pick  something  up  from  the  floor.  The 
starting-point  is  a  thrombus  of  the  femoral,  the  uterine,  or  the  ovarian 
veins,  or  the  vena  cava.  As  a  rule,  one  of  the  chief  trunks  of  the  pul- 
monary artery  is  suddenly  obstructed,  causing  violent  dyspnoea,  cyan- 
osis, and  almost  immediate  death.  In  more  fortunate  cases  only  a 
smaller  branch  is  obstructed,  when  the  dyspnoea  and  cyanosis  are 
more  moderate  and  recovery  is  possDDle. 

In  such  cases  of  venous  obstruction,  especially  phlegmasia  alba 
dolens,  there  may  be  no  warning  sign  of  impending  danger ;  in  others 
the  thrombus  may  irritate  the  vein  and  cause  phlebitis  with  rise  in 
temperature  and  increase  of  the  frequency  of  the  pulsation. 

Sudden  emotions  of  joy,  sorrow,  or  fright  may  cause  instant 
death. 

Puerperal  infection  may  also  take  so  acute  a  form  that  it  kills  in 
less  than  twenty-four  hours. 

In  some  cases  sudden  or  rapid  death  is  due  to  a  faulty  use  of 
antiseptic  drugs.     An   assistant   of    mine,  in  introducing  the  intra- 


550  ABNORMAL    LABOR. 

uterine  tube,  perforated  the  wall  of  the  cervical  canal  and  injected  a 
one-to-two-thousand  solution  of  bichloride  of  mercury  into  the  peri- 
toneal cavity.  Another,  in  order  to  wash  out  the  uterus  with  a  one 
per  cent,  solution  of  carbolic  acid,  used  a  double-current  catheter,  but 
connected  the  afferent  tube  with  the  wide  metal  tube  of  the  catheter 
instead  of  with  the  narrow.  The  autopsy  showed  that  the  uterus, 
wliich  in  consequence  of  dissecting  metritis  had  become  very  thin  in 
some  places,  had  been  ruptured,  allowing  the  fluid  to  enter  the  peri- 
toneal cavity. 

Corrosive  sublimate  is  so  dangerous  in  puerperal  women  that  it 
should  not  be  used  at  all  for  vaginal  or  intra-uterine  injections.  In 
1889  the  writer  collected  twenty  fatal  cases  due  to  this  drug  in 
obstetric  practice  alone  and  added  two  observed  by  himself.^ 

Carholic  add  has  also  caused  rapid  death  by  absorption.  It  should 
not  be  used  in  stronger  solution  than  two  per  cent,  in  the  uterus  and 
vagina. 

CHAPTER   XVII. 
CHILDBIRTH   AFTER    THE   DEATH    OF   THE    MOTHER. 

Somatic  death  is  not  an  instantaneous  event.  Death  is  a  gradual 
process.  Even  in  a  case  of  sudden  death  one  literally  dies  by 
inches.-  A  headless  chicken  may  be  seen  running  about  in  a  barn- 
yard. If  one  chops  off  the  head  of  a  calf,  for  several  minutes  the 
severed  head  will  show  signs  of  difficult  breathing.  If  the  tip  of  a 
finger  be  brought  close  to  the  eye,  the  eye  will  wink,  just  as  does  that 
of  a  live  animal.  If  the  cavity  of  the  chest  be  opened,  the  heart  will 
be  seen  to  continue  to  contract  and  relax  for  a  long  time.  One  may 
even  cut  out  the  heart  altogether  and  place  it  under  a  glass  shade, 
and  still  its  rhythmic  movements  continue.  This  life  of  the  organs  is 
shown  still  more  impressively  by  opening  the  carotid  in  a  dog  and 
letting  him  bleed  to  death.  There  comes  a  moment  when  the  dog 
dies,  and  life  would  remain  extinct  if  the  animal  was  left  to  himself. 
But  if  the  severed  vessel  be  tied  and  blood  from  another  dog  be 
injected,  the  dead  dog  will  return  to  life  and  may  continue  living  as 
long  and  in  as  perfect  health  as  if  he  had  not  been  subjected  to  any 
experimentation.  This  is  due  to  the  hfe  remaining  in  the  tissues 
which  enables  them,  under  the  impulse  of  fresh  blood,  to  resume  all 
the  suspended  vital  functions. 

The  writer  has  seen  the  ciliated   epithelium  in  the  interior  of 

^  Garrigues,  "Corrosive  Sublimate  and  Creolin  in  Obstetric  Practice,"  Amer. 
Jour.  Med.  Sci.,  August,  1889. 

^  Garrigues,  ' '  The  Legislation  needed  in  Regard  to  Apparent  Death, ' '  Med. 
News,  April  14,  1900. 


CHILDBIRTH   AFTER   THE   DEATH    OF   THE    MOTHER.  551 

an  ovarian  tumor  of  a  woman  in  full   movement  the  day  after  its 
extirpation. 

There  is,  therefore,  nothing  remarkaJjle  in  the  fact  that  a  child 
may  be  born  after  the  death  of  its  mother,  if  by  her  death  we  under- 
stand that  respiration  has  stopped  and  the  heart  has  ceased  beating. 
The  uterus  retains  its  power  of  contractility,  and  may  expel  the  foetus 
dead  or  alive.  As  a  rule,  in  such  cases  the  mother  is  exhausted  by 
previous  illness  or  the  pangs  of  a  protracted  labor,  and  then  the 
foetus  will  soon  che  undelivered,  from  asphyxia.  To  be  born  alive  it 
must  leave  the  maternal  body  within  a  few  minutes,  probably  at  inost 
within  a  quarter  of  an  hour.  In  the  great  majority  of  cases  of  spon- 
taneous births  after  the  death  of  the  mother  the  child  was  dead. 

But  the  case  is  quite  different  if  a  pregnant  woman  at  term  or  in 
actual  normal  labor  is  suddenly  killed.  Under  such  circumstances  a 
living  child  has  been  removed  from  its  mother's  body  by  Caesarean 
section  one  and  even  two  hours  after  her  death. 

From  the  old  Romans  a  law  has  been  inherited  and  incorporated 
in  the  statutes  of  most  countries  to  the  effect  that  when  a  pregnant 
Avoman  dies,  and  the  child  is  alive,  it  shall  be  the  duty  of  the  attend- 
ing physician  to  perform  Caesarean  section  at  once,  with  the  aim  of 
saving  the  life  of  the  foetus.  This  seemingly  humane  law  is,  however, 
beset  with  difficulties  in  its  practical  application.  The  distinction  be- 
tween real  and  apparent  death  being  a  most  delicate  matter,  it  has 
happened  more  than  once  that  the  supposed  dead  woman,  under  the 
stimulus  of  the  pain  inflicted  by  the  surgeon's  knife,  returned  to  life, 
to  the  dismay  of  the  operator  and  the  horror  of  her  friends.  It  may, 
therefore,  be  laid  down  as  a  rule  that  it  is  not  safe  to  perform  Caesarean 
section  otherwise  than  according  to  the  rules  of  surgery.  I  do  not 
mean  that  the  accoucheur  should  take  the  time  to  provide  for  an 
aseptic  and  antiseptic  operation,  as  he  would  and  should  under  ordi- 
nary circumstances,  but  the  necessary  material  and  implements  for 
uniting  the  wounds  in  the  uterus  and  the  abdominal  wall  should  be 
present. 

The  value  of  the  operation  cannot  be  doubted.  Puech  found 
that  in  453  post-mortem  Caesarean  sections  the  child  showed  signs  of 
life  in  101  cases  and  continued  to  live  in  43  cases. 

Since  the  life  of  the  foetus  is  extinct  so  soon  after  the  mother's 
death,  the  proposition  has  been  made  not  to  wait  for  her  death,  but 
to  operate  while  she  is  dying.  If  great  interests  were  at  stake,  and 
the  dying  woman  herself  desired  to  have  the  operation  performed, 
this  might  be  considered ;  but  under  ordinary  circumstances  I  think 
the  physician  should  be  guided  by  the  rules  that  the  mother  is  a  really 
existing  human  being,  while  the  child,  until  it  is  born,  is  only  a  possi- 
bility, and  that  it  is  his  duty  to  prolong  life.     Now,  there  cannot  be 


552  ABNORMAL   LABOR. 

any  doubt  that  when  a  woman's  hfe  is  ebbing  away  the  infliction  of 
the  wounds  necessary  for  the  performance  of  Caesarean  section  will 
hasten  her  death,  and  still  more  the  administration  of  an  aneesthetic, 
if  such  is  used.  It  would  be  especially  unjustifiable  and  revolting  to 
exercise  any  kind  of  pressure  to  induce  the  dying  woman  to  give  her 
consent  to  the  operation. 

If  the  OS  is  well  dilated,  the  pelvis  normal,  and  the  fa?tus  of  aver- 
age size,  it  may  be  possible  to  turn  the  foetus  and  extract  it  manually 
in  as  short  time  as  that  reciuired  for  Ctesarean  section,  or  if  the  head 
is  already  engaged  a  forceps  operation  may  also  be  successful. 

Some  go  so  far  as  to  think  that  even  if  the  foetus  is  dead  it  should 
be  extracted  from  the  maternal  body,  either  per  vias  naturales  or  by 
Caesarean  section.  The  only  real  advantage  the  writer  sees  in  per- 
forming this  jDost-mortem  would  be  to  avoid  the  possDile  spontaneous 
expulsion  of  the  child,  which  might  give  rise  to  the  belief  that  the 
woman  was  not  dead  and  was  deserted  by  the  attendant  accoucheur. 
Such  expulsion  from  the  dead  body  of  the  mother  may,  indeed,  take 
place  days  after  death  has  occurred,  and  is  then  no  longer  a  vital 
process,  but  simply  an  effect  of  the  mechanical  pressure  exercised  on 
the  fundus  uteri  by  the  development  of  gas  in  the  abdominal  ca^dty 
in  consequence  of  putrefaction.  While  the  vital  process  of  uterine 
contraction  stops  soon  after  death,  the  chemical  function  of  putrefac- 
tion, ushered  in  by  microbic  invasion,  begins  later  and  goes  on  till  the 
abdominal  wall  ruptures.  To  this  category  belong  the  cases  in  which, 
on  reo23ening  coffins,  a  dead  child  was  found  lying  outside  of  a  dead 
mother. 


CHAPTER   XVIII. 

INJURY   TO    THE    FCETUS  DURING   LABOR. 

Serious  lesions  of  the  foetus,  such  as  fractures  of  the  cranial  bones, 
the  cervical  vertebrae,  the  collar-bone,  the  humerus,  the  lower  jaw,  and 
paralysis  of  the  upper  extremities,  occur  most  frecjuently  in  cases  of 
narrow  pelves  (pp.  460,  462).  They  may  either  be  spontaneous  or  be 
due  to  operative  manipulations.  In  the  latter  case  they  are  sometimes 
unavoidable,  but  much  more  frequently  they  are  produced  by  lack  of 
skill  and  cautiousness  on  the  part  of  the  obstetrician.  Thus  the  skin 
may  be  scratched.  The  eyes  are  particularly  exposed  in  face  presen- 
tations and  in  delivery  by  pressure  from  the  rectum.  In  breech 
presentations  the  anus  and  genitals  may  be  wounded.  The  worst  the 
writer  has  seen  in  this  line  was  a  case  of  pelvic  presentation  of  a 
female  child,  in  which  tlie  attending  physician,  in  trying  to  apply  the 


INJURY   TO    THE    F(ETUS   DURING   LABOR.  553 

forceps  to  what  he  took  to  be  the  head,  hiserted  one  blade  into  the 
pelvis  of  the  foetus  and  tore  the  genitals  and  intestine  to  pieces. 

In  breech  presentations  injuries  to  the  soft  parts  of  the  groin  are 
not  rare.  They  are  due  to  pressure  with  the  fingers,  the  fillet,  or  the 
blunt  hook  (pp.  387-389). 

Rough  manipulation  of  the  abdomen  during  extraction  has  led  to 
rupture  of  the  hver  and  to  hemorrhage  in  the  suprarenal  capsule.  Too 
violent  movements  in  reviving  asphyxiated  children  by  Schultze's 
method  have  also  led  to  such  hemorrhage  and  even  to  avulsion  of  the 
spleen. 

In  forceps  extractions  a  blade  may  press  so  much  on  the  facial 
nerve  on  one  side  that  the  child  is  born  with  a  paralysis  of  one  side 
of  the  face.  This,  however,  is  a  transient  lesion,  which  passes  off  in 
a  week  or  two  without  treatment. 

Some  conditions  demand  a  more  detailed  description  in  this  place. 

§  1.  Cephalaeinatoma.  —  Cephalaematoma  is  an  extravasation  of 
blood  between  the  periosteum  and  the  bones  of  the  cranium.  It  forms 
a  globular  or  ovoid  fluctuating  tumor  and  is  always  limited  to  the 
contour  of  a  bone,  the  periosteum  being  so  tightly  adherent  to  the 
edges  of  the  bones  that  the  blood  cannot  pass  this  barrier. 

Diagnosis. — This  limitation  within  the  edges  of  a  bone  and  the 
fluctuation  distinguish  cephalaematoma  from  caput  succedaneum^  which, 
situated  between  the  periosteum  and  the  scalp,  can  spread  in  all  direc- 
tions, and  gives  a  doughy  sensation,  the  blood  and  serum  filling  the 
meshes  of  the  subcutaneous  connective  tissue. 

The  cephalaematoma  may  be  limited  to  one  bone  or  found  on  two, 
three,  and  even  four  bones  simultaneously  (Fig.  399).  It  is  most  com- 
mon on  the  anterior  parietal  bone,  but  is  found  also  on  the  posterior 
parietal,  the  frontal,  and  the  occipital  bones. 

The  blood  is  fluid  and  dark.  The  swelling  increases  during  the 
first  week  after  birth,  when  involution  begins.  In  the  circumference 
a  ring  of  callus  is  formed  and  felt  as  a  hard  bony  mass,  in  comparison 
to  which  the  soft  centre  makes  the  impression  of  a  hole.  In  most  cases 
the  blood  and  callus  are  slowly  reabsorbed,  and  finally  the  swelling 
totally  disappears,  but  this  process  of  involution  may  take  three  or  four 
months.  In  rare  cases  the  bone  formation  continues,  and  a  parch- 
ment-like roof  is  formed  over  the  blood,  which  on  pressure  emits  a 
crepitus-like  sound.  This  process  of  ossification  may  go  still  farther 
and  result  in  an  exostosis.  In  other  cases  the  contents  of  the  swell- 
ing may  become  purulent. 

Etiology. — The  chief  cause,  as  in  caput  succedaneum,  is  doubtless 
pressure,  and  the  two  affections  are  often  combined,  the  ceplialaema- 
toma  being  concealed  the  first  days  by  the  more  superficial  and  wide- 
spread caput  succedaneum.     Autopsies  have  also  shown  that  below 


554  AB^X)RMAL    LABOR. 

the  caput  succedaneiim  may  be  found  small  ceplialtematomas  Avliicli 
had  not  the  requisite  dimensions  to  make  themselves  clinically  kno^^  n. 
Cepliala?matoma  is  much  more  common  in  primiparse  than  in 
women  "\Aiio  have  borne  cliilch'en  before,  and  therefore  offer  less  re- 
sistance to  the  passage  of  the  foetus.  A  narrow  pehis  predisposes  to 
it.  It  may  be  due  to  prti-ssure  with  the  forceps  or  to  manual  extrac- 
tion. The  bleedmg  is  caused  by  a  detacliment  of  the  periostemn, 
which  membrane  is  being  pushed  aside  by  pressure,  especially  against 
the  pubic  arch  or  the  promontory.  In  other  cases  there  is  formed  a 
iissm'e  in  the  bone,  and  then  the  blood  may  not  only  collect  on  the 

Fig.  399. 


Double  cephalaematxjma.     ( .Ahlfeld.j 

outer  surface  of  the  bone,  but  also  inside,  between  the  bone  and  the 
dura  mater. — iidcnxol  rfpholxprnotomo. 

Tlie  extravasation  may  also  be  due  to  intra-uterine  asphyxia,  with 
the  concomitant  cons-estion  of  the  h':-ad  of  the  foetus,  and  alDuormal 
fluidity  of  the  blood,  and  it  may  therefore  be  fomid  in  small  children 
and  where  there  was  no  obstruction  in  the  maternal  parts.  It  has 
been  seen  combined  Avith  bleeding  from  the  genitals  or  melsena,  which 
conditions  were  also  referable  to  internal  stasis  of  blood  and  rup- 
ture of  vessels  in  the  mucosa  of  the  uterus  or  the  intestine. 

The  author  has  observed  a  r-ase  in  Avhicli  the  child,  who  was  of 
the  male  sex.  late-r  appeared  to  be  suffering  ff'om  htemophilia.  A 
common  little  knock  would  cause  lai^e  subcutaneous  extravasations. 
These  being  in  different  degrees  of  absorption,  his  body  was  not  un- 
like a  colored  map.  and  he  came  near  losmg  his  life  once  for  having 
a  milk-tooth  pulled. 


IXJURY    TO    THE    FCETUS   DURING   LABOR.  555 

Treatment. — Small  cephalasmatomas  may  be  left  untouched.  In 
larger  ones  the  process  of  repair  may  be  much  expedited  and  the  for- 
mation of  an  exostosis  prevented  by  evacuating  the  tumor  with  an 
aspirator  or  small  incision,  followed  by  compression  with  straps  of 
rubber  adhesive  plaster.  Before  making  any  wound  the  skin  should 
be  shaved  and  disinfected  with  bichloride  and  alcohol. 

If  an  abscess  forms,  which  may  be  inferred  when  the  swelling 
becomes  red,  hot,  and  painful,  and  the  child  has  fever,  it  should  be 
opened  and  drained,  as  otherwise  it  might  lead  to  meningitis. 

§  2.  Asphyxia. — Originally  meaning  pulselessness,  the  word  as- 
phyxia nowadays  means  a  condition  of  impeded  or  suspended  res- 
piration. Nomially  the  foetus,  while  in  its  mother's  body,  is  in  a  state 
of  apnoea, — that  is  to  say,  its  blood  being  oxygenated  in  the  placenta, 
it  has  no  desire  for  air  and  does  not  attempt  to  breathe.  But  as  soon 
as  anything  interferes  with  the  uteroplacental  circulation,  the  supply 
of  oxygen  becomes  insufficient,  effete  matter  accumulates  in  the  fetal 
blood,  and,  in  consequence  of  irritation  of  the  medulla,  the  foetus  at- 
tempts to  breathe.  The  thorax  is  expanded  and  works  like  a  pump, 
but,  since  there  is  no  air  in  the  uterus,  the  foetus  cannot  breathe  ;  it 
is  in  the  condition  called  asphyxia.  This  may  be  intra-uterine  or 
persist  after  the  birth  of  the  child. 

Intra-uterine  Asphyxia. — This  may  be  due  to  the  mother's  death 
or  loss  of  blood,  or  to  diseases  that  diminish  the  oxygen  circulating  in 
the  maternal  body, — for  instance,  pneumonia  or  eclampsia ;  to  pre- 
mature detachment  of  the  jDlacenta,  especially  placenta  praevia,  more 
rarely  of  a  normally  inserted  placenta ;  to  compression  of  the  um- 
bilical cord ;  or  to  diseased  conditions  of  the  placenta,  by  which  the 
area  of  exchange  between  maternal  and  fetal  blood  becomes  restricted 
beyond  the  physiological  limits  which  are  found  in  every  case  of 
pregnancy  (p.  129).  It  may  also  be  brought  about  by  tetanic  con- 
traction of  the  uterus,  in  wiiich  the  normal  intervals  between  uterine 
contractions  do  not  occur.  Indirectly  it  may  therefore  be  due  to  the 
administration  of  ergot. 

Asphyxia  may  arise  also  in  consequence  of  pressure  on  the  fetal 
head.  A  narrow  pelvis  or  too  large  a  size  of  the  foetus  may  therefore 
become  a  predisposing  cause  of  asphyxia,  whether  the  woman  de- 
livers herself  or  the  foetus  is  extracted  manually  or  by  means  of  for- 
ceps. The  compression  of  the  head  irritates,  indeed,  the  pneumo- 
gastric  nerve,  which  retards  and  finally  arrests  the  contraction  of 
the  fetal  heart.  The  compression  of  the  head  may  also  fracture  the 
bones  of  the  skull  and  cause  intracranial  extravasation  of  blood.  On 
the  hemispheres  this  may  be  well  borne  and  the  blood  may  be  re- 
absorbed, but  on  the  base  of  the  brain  such  extravasation  is  very 
dangerous. 


556  ABNORMAL   LABOR. 

The  expansion  of  the  thorax  produces  a  dilatation  of  the  right 
ventricle,  which  in  the  normal  condition  pushes  a  large  current  of 
blood  through  the  duct  of  Botallo  and  the  descending  aorta  and  its 
branches  to  the  placenta.  Also  in  this  way  the  attempt  at  breathing 
contributes  to  interference  with  the  free  circulation  in  the  placenta. 

The  immediate  effect  of  the  expansion  of  the  chest  is  that  the 
liquids  Avith  which  the  mouth  of  the  foetus  is  in  contact — liquor 
amnii,  mucus,  blood,  meconium — are  sucked  into  the  air-passages, 
wliere  they  are  found  at  the  autopsy  on  children  who  died  asphyx- 
iated. If,  however,  the  mouth  and  nostrils  are  in  contact  with  the 
wall  of  the  parturient  canal,  this  aspiration  of  foreign  substances  can- 
not take  place,  and  they  are  not  found  in  the  air-passages  after  the 
death  of  the  child. 

Another  effect  of  the  premature  expansion  is  attraction  of  blood 
to  all  the  thoracic  organs,  which  leads  to  the  rupture  of  the  fine 
blood-vessels.  In  the  living  asphyctic  child  there  is  often  found 
bloody  mucus  in  the  trachea,  and,  while  this  blood  may  have  been 
aspirated  from  the  genital  tract  of  the  mother,  or  may  come  from 
wounds  inflicted  by  the  obstetrician  in  his  endeavors  to  save  the 
child's  life,  part  of  it  may  come  also  from  ruptured  capillaries  in 
the  mucous  membrane  of  the  fetal  air-passages  themselves.  At  the 
autopsy  on  children  who  died  from  asphyxia  are  also  constantly 
found  ecchymoses  under  the  pleura  and  the  pericardium,  and  the 
lungs  are  found  in  a  high  state  of  congestion. 

Clinically,  there  are  well-marked  signs  which  warn  the  physician 
of  the  peril  in  which  the  unborn  child  is  placed.  Sometimes  the 
foetus  makes  at  first  unusually  violent  movements,  which  can  be  seen 
and  felt,  but  this  is  only  a  transition  to  the  opposite  condition  of  slow 
movements  followed  by  the  immobility  of  death.  As  a  rule,  the  pul- 
sations of  the  heart  become  much  slower.  Normally  the  heart-sounds 
become  slower  during  uterine  contractions,  but  this  retardation  is 
comparatively  insignificant,  and  is  equalized  by  a  faster  rhythm  in  the 
interval  between  labor-pains.  When  the  heart-beat  drops  to  100  per 
minute,  the  life  of  the  foetus  is  in  danger.  If  the  umbilical  cord  is 
within  reach,  the  corresponding  retardation  of  pulsation  is  felt  there. 

Exceptionally,  the  heart-beat,  instead  of  being  retarded,  is  much 
increased  in  frequency,  even  up  to  200  beats  in  a  minute.  This  is 
particularly  observed  in  cases  of  sudden  impaction  of  the  head  in  a 
narrow  pelvis,  and  the  explanation  of  the  occurrence  is  probably  to  be 
sought  in  the  suddenness  and  vigor  of  the  compression  of  the  head, 
which  paralyzes  the  pneumogastric  nerve  instead  of  stimulating  it. 

Another  sign  of  asphyxia  is  the  expulsion  of  meconium.  If  the 
foetus  is  in  head  or  transverse  presentation,  the  admixture  of  meco- 
nium to  the  liquor  amnii  is  a  sign  of  some  importance,  but  even  then 


INJURY    TO    THE   FCETUS   DURING   LABOR.  557 

the  child  may  be  born  m  good  condition.  Tlie  explanation  of  this  is 
probably  that  the  child  at  a  time  was  asphyctic  and  that  the  disturb- 
ing element  was  eliminated.  In  pelvic  presentation  the  expulsion  of 
meconium  has  much  less  value,  since  it  may  be  due  to  simple  me- 
chanical pressure  on  the  abdomen  of  the  foetus.  Quinine  given  to 
the  mother  during  labor  also  causes  the  meconium  to  be  expelled. 

If  the  hand  of  the  accoucheur  is  introduced  into  the  uterus,  he 
may  directly  feel  the  respiratory  movements  of  the  foetus.  He  may 
likewise  through  the  perineum  or  rectum  feel  the  mouth  open.  In 
manual  extraction  we  may  see  the  movements  of  the  thorax  and 
abdomen,  while  the  head  is  still  in  the  pelvis. 

The  asphyxia  produces  a  general  lack  of  tonus,  which  shows  itself 
in  the  expulsion  of  the  meconium  and  the  urine,  in  prolapse  of  ex- 
tremities, and  in  brow  and  face  presentations. 

In  rare  cases  the  foetus  may  even  be  heard  to  cry  in  the  uterus, — 
so-called  vagitus  uterinus.  This  is  only  possible  when  air  in  some 
manner  finds  its  way  into  the  uterus, — for  instance,  alongside  of  the 
hand  or  instruments  that  are  introduced  through  the  vagina.  The 
asphyctic  foetus  then  inhales  this  air  and  expels  it  again,  whereby  the 
sound  is  produced. 

Intra-uterine  asphyxia  is  a  dangerous  condition  that  frequently 
leads  to  death,  and,  therefore,  often  calls  for  the  interference  of  the 
physician  in  order  to  save  the  life  of  the  foetus.  This  may  be  done 
by  forceps  if  the  head  is  engaged,  or  by  extraction  if  it  is  still  above 
the  brim,  either  of  which  operations  should  be  performed  only  after 
obliteration  of  the  cervix  and  full  dilatation  of  the  os. 

Asphyxia  after  Birth. — If  the  child  does  not  breathe  promptly 
after  having  been  born,  it  is  said  to  be  asphyctic,  but  this  asphyxia 
may  be  so  slight  that  it  is  of  little  importance  and  would  soon  cease 
spontaneously ;  or,  again,  it  may  be  so  deep  that  it  is  impossible  to 
make  the  child  breathe,  or  that,  even  if  it  survives  temporarily,  it  dies 
within  a  few  days. 

Cases  of  asphyxia  after  birth  present  great  medicolegal  interest,^ 
and  the  history  of  medicine  bears  testimony  that  even  great  obstetri- 
cians have  shown  a  remarkable  lack  of  appreciation  of  what  consti- 
tutes life.  The  laws  of  different  countries  also  vary  considerably 
in  their  determination  of  what  constitutes  a  living  child.  A  double 
interest  attaches  to  the  cjuestion :  on  the  one  hand,  the  criminality  of 
maltreating  the  child ;  on  the  other  hand,  its  capability  of  inheriting 
and  transmitting  property.  The  Roman  law  required  that  it  should 
be  perfectly  alive,  but  it  needed  not  to  make  its  voice  heard.  In 
France  the  law  requires  that  the  child  shall  be  born  viable,  and  the 

^  Garrigues,  "Asphyxia  in  New-born  Children  considered  from  a  Medical  and 
a  Legal  Stand-point,"  Amer.  Jour.  ObsLet.,  vol.  xi.,  No.  4,  October,  1878. 


558  ABNORMAL   LABOR. 

interpretation  of  ttie  terms  life  and  horn  alive  is  complete  and  per- 
fect respiration.  According  to  Scotch  law  the  child  must  cry.  The 
English  law  is  much  more  in  accordance  with  medical  science.  "  Cry- 
ing," says  Blackstone,  "  is  the  strongest  evidence  of  life,  but  it  is  not 
the  only  evidence."  Coke  says,  "  Crying  is  but  a  proof  that  the  child 
was  born  alive,  and  so  is  motion,  stirring,  and  the  like."  Dunlope 
laid  down  the  right  principle  that,  where  there  is  power  of  being 
affected  by  stimuli  other  than  electric,  this,  in  common  sense,  must 
be  held  to  constitute  vitality. 

In  several  cases  of  alleged  infanticide  the  English  judges,  in  charg- 
ing the  jury,  said  that  a  child  may  be  born  alive  and  live  for  some 
time  without  breathing.  In  fact,  it  would  appear  that  breathing  is 
regarded  as  only  one  proof  of  life,  and  the  law  will  receive  any  other 
evidence  which  may  satisfactorily  show  that  a  child  has  lived.  A 
child  that  is  born  alive,  or  has  come  entirely  into  the  world  in  a  living 
Slate,  may,  by  English  law,  inherit  and  transmit  property  to  its  heirs, 
even  although  its  death  has  immediately  and,  from  morbid  causes, 
perhaps  necessarily  followed  its  birth.  The  mere  warmth  of  the  body 
is  not  enough  to  be  evidence  of  life  ;  but  the  slightest  trace  of  vital 
action,  in  its  common  and  true  physiological  acceptation — such  as 
crying,  breathing,  pulsation,  or  motion,  be  it  only  the  twitching  of  an 
eyelid, — observed  after  entire  separation  from  the  mother,  without 
regard  to  cord  and  placenta,  would  be  deemed  in  English  law  a  suffi- 
cient proof  of  the  child  having  come  into  the  world  alive.  But  the 
reader  should  notice  that  in  the  eyes  of  the  law  the  child  is  not  born 
until  every  part  of  its  body  is  outside  of  the  maternal  body.  The 
writer  has,  therefore,  made  it  a  rule  always  to  extract  even  the  tips 
of  the  toes  from  the  genital  canal  when  the  trunk  has  been  expelled. 
If  a  case  of  this  kind  should  come  up  in  this  country,  the  decisions 
of  the  English  courts  in  similar  cases  would  be  considered  the  law. 
As  practitioners  we  should  use  every  effort  to  make  the  child  cry,  this 
being,  to  the  popular  mind,  the  convincing  proof  of  its  being  alive, 
which  will,  perhaps,  save  the  trouble  and  expense  of  a  lawsuit,  and 
which  also  gives  hope  of  keeping  it  alive  ;  but  as  expert  witnesses  we 
must  remember  that  life  may  be  manifested  in  many  other  ways.  As 
long  as  active  motion  goes  on, — such  as  pulsation  felt  or  heard  in  the 
heart,  pulsation  in  the  cord  after  the  child  has  been  entirely  expelled 
or  extracted  from  the  mother's  body,  the  faintest  respiratory  gasp,  or 
a  movement  of  the  lips,  of  an  eyelid,  or  of  a  limb, — life  is  not  extinct. 
Any  maltreatment  of  the  child  is  a  crime,  and  it  has  the  right  of 
inheriting  and  transmitting  property. 

The  asphyctic  child  may  present  two  very  different  appearances, 
which  are  of  great  importance  as  to  prognosis  and  treatment.  The 
child  may  either  be  purple  and  turgid  or  pale,  wax-like,  and  limp.    In 


INJURY   TO    THE    FCETUS   DURING   LAROR.  559 

the  pmyle  variety  tlie  outlook  for  its  recovery  and  continuance  of  life 
is  much  more  promising  tlian  in  the  _pa^e  variety.  Even  if  we  suc- 
ceed in  making  the  child  cry,  it  often  dies  within  a  few  days.  This 
may  be  due  to  a  deglutition  pneumonia  or  general  sepsis  caused  by 
the  foreign  bodies  which  have  been  drawn  into  the  lungs.  Or  larger 
lumps  may  block  up  a  bronchus  and  prevent  air  from  entering  the 
alveoli — so-called  atelectasis. 

Besides  the  color,  there  are  other  signs  by  which  slight  asphyxia 
may  be  distinguished  from  deep.  If  the  little  finger  is  introduced 
into  the  throat,  the  faucial  muscles  in  light  and  middling  degrees  of 
asphyxia  grasp  it,  while  in  deep  asphyxia  no  such  movement  is 
elicited,  and  the  lower  jaw  falls  down.  If  the  frequency  of  the  heart- 
beat is  increased  in  a  marked  degree  by  cutaneous  irritation,  the  out- 
look is  also  good.  Cases  have  even  been  reported  in  which  there 
were  no  audible  heart-sounds,  and  still  the  child  was  revived.  Ahl- 
feld  has  had  four  cases  in  which  there  was  respiration,  but  no  trace 
of  heart-sounds.  It  is  therefore  better,  in  cases  of  apparent  death 
of  the  child,  unless  there  is  positive  proof  of  its  real  death,  to  try  to 
revive  it. 

Treatment. — In  the  author's  experience  one  of  the  most  effective 
means  of  making  the  child  cry  is  to  immerse  its  whole  body,  except 
the  head,  alternately  into  very  warm  and  ice-cold  water.  I  therefore 
always  direct  the  people  to  have  plenty  of  hot  water,  ice,  and  two  ves- 
sels large  enough  to  dip  the  child  in.  The  water  should  be  so  hot 
that  the  accoucheur  can  just  hold  his  hands  in  it  (about  110°  F.).  In 
winter-time  the  water  as  it  flows  from  the  hydrant  is  cold  enough,  and 
still  the  direct  rubbing  of  the  abdomen  with  a  lump  of  ice  has  proved 
useful  in  my  hands.  A  baby  bath-tub  is  very  convenient,  but  a  foot- 
bath-tub, a  wash-tub,  a  dish-pan,  or  large  basin  will  do.  The  child 
should  always  first  be  placed  in  the  hot  water,  as  this  draws  the 
blood  away  from  the  congested  lungs  and  brain  to  the  capillaries  of 
the  skin.  It  should  also  be  held  twice  as  long  in  the  hot  water  as  in 
the  cold,  in  which  it  remains  only  a  few  seconds.  While  it  is  in  the 
water  the  skin  of  the  trunk  and  extremities  should  be  rubbed  rather 
roughly.  The  first  cry  comes  invariably  while  the  child  is  in  the  cold 
water.  After  that  it  is  taken  out,  rubbed  well  with  warm  cloths,  and 
dressed. 

If  the  immersion  in  hot  and  in  cold  water  and  rubbing  do  not  act 
promptly,  I  slap  the  child  on  the  buttocks,  and  if  that  does  not  make 
it  cry,  I  resort  to  B.  S.  Schultze's  swingings  (Figs.  400,  401).  For 
this  purpose  the  child  is  held  a  little  in  front  of  the  accoucheur,  its 
back  turned  towards  him.  He  places  his  thumbs  in  front  of  the 
shoulders  and  the  fingers  behind,  the  index-finger  resting  in  the 
axilla.      The    child's   body    hangs    down.     The    head   is    supported 


560 


ABNORMAL   LABOR. 


between  the  accoucheur's  wrists,  so  as  to  prevent  it  from  falling  for- 
ward and  backward.  Next,  a  movement  is  imparted  to  the  child's 
body  by  which  it  is  doubled  up,  the  buttocks  forming  the  highest 
point  and  the  legs  hanging  down  between  the  head  and  the  accou- 
cheur. Then  the  movement  is  reversed,  so  that  the  child  again  is 
made  to  hang  down,  and  so  forth.     These  movements  should  by  no 

means  be  violent,  nor  should  they  be 
repeated  in  too  rapid  succession ; 
from  ten  to  fifteen  times  a  minute  is 
enough,  and  the  movement  should 
not  be  stronger  than    just  what  is 

Fig.  401. 


Fig.  400. 


B.  S.  Schultze's  swingings. 

needed  to  produce  the  change  in  posture  of  the  child.  In  the  stretched 
position  the  thoracic  cavity  is  enlarged  and  air  is  aspirated.  In  the 
doubled-up  posture,  the  thorax  is  forcibly  compressed  in  imitation  of 
a  forced  expiration.  Schultze  claims  that  this  expiration  suffices  even 
to  expel  the  liquids  that  have  been  drawn  into  the  lungs,  but  that  is 
not  always  so.  These  swingings  may  be  repeated  many  times.  Some 
report  to  have  repeated  them  fifty  times,  others  even  six  hundred 
times.     I  have  never  approached  such  vigorous  treatment.     When  I 


INJURY   TO   THE   FCETUS   DURING   LABOR.  561 

have  swung  the  child  a  few  times,  I  repeat  the  hot  and  cold  bath, 
then  again  make  swingings,  and  so  forth.  But  if  I  do  not  soon  see 
an  improvement  in  the  child's  condition,  I  discontinue  these  means, 
wrap  the  child  in  warm  cloths,  and  use  the  larynx  catheter. 

Many  severe  injuries  have  been  reported  in  consequence  of  the 
Schultze  method ;  but  I  am  inclined  to  think  that  it  was  not  the 
method,  but  the  accoucheur,  which  was  at  fault.  The  collar-bone 
and  ribs  have  been  broken  and  the  ends  made  to  wound  the  lungs. 
Hemorrhage  has  occurred  in  the  suprarenal  capsules,  and  the  liver 
has  ruptured.  Even  the  whole  spleen,  which  was  enlarged,  has  been 
torn  off  completely  and  found  lying  loose  in  the  blood-filled  abdominal 
cavity. 

If  the  aspirated  fluids  are  heard  producing  rales  in  the  trachea  and 
bronchi  and  are  not  expelled  by  Schultze  movements,  an  elastic  cath- 
eter (but  not  one  of  soft  rubber)  should  be  introduced  into  the  larj'ux. 
It  should  be  of  medium  size, — about  No.  9  French.  The  child  lies, 
warmly  wrapped  up,  on  its  back.  The  accoucheur  inserts  his  left 
index-finger  and  lifts  the  epiglottis  with  it.  Next,  he  slides  the  cath- 
eter, which  should  be  luiDricated  Avith  white  vaseline,  along  the  finger 
into  the  trachea  and  down  to  the  bifurcation.  Then  he  applies  his 
mouth  to  the  upper  end  of  the  catheter  and  makes  suction  while  he 
slowly  withdraws  the  catheter.  If  necessary,  he  repeats  this  pro- 
cedure until  all  mucus,  blood,  meconium,  and  liquor  amnii  have  been 
removed.  If  only  one  side  of  the  thorax  expands,  it  is  a  sign  that 
the  bronchus  of  the  other  side  is  obstructed,  and  by  turning  the  cath- 
eter in  this  direction  the  accoucheur  may  be  able  to  free  it  from  the 
obstructing  substances. 

If  the  child  now  breathes  freely,  notliing  more  is  called  for ;  but 
if  it  remains  asphyctic,  the  catheter  is  again  introduced  and  used  for 
another  purpose.  Now  the  accoucheur  no  longer  aspirates,  but  blows 
air  into  the  trachea  and  bronchi.  In  order  to  avoid  rupturing  the 
alveoli  and  producing  an  emphysema,  the  air  should  be  blown  in 
with  very  little  force ;  and,  in  order  that  the  air  may  contain  as  much 
oxygen  as  possible,  only  air  from  the  upper  air-passages  should  be 
used.  The  air  should  only  be  propelled  by  movements  of  the  cheeks, 
and  not  by  usmg  the  expiratory  muscles  of  the  thorax.  The  author 
lias  used  this  method  of  insufflation  frequently.  He  did  not  find  it 
difficult  to  execute,  and  he  has  seen  excellent  results  from  it. 

The  methods  of  Marshall  Hall  and  Silvestci-  are  of  less  value  on 
account  of  the  softness  of  the  fetal  bones  and  cartilages.  Marshall 
HalFs  method  consists  in  simply  turning  the  child  alternately  on  the 
back  and  the  side.  Silvester's  method  consists  in  alternately  stretch- 
ing the  arms  up  alongside  of  the  head  and  presshig  the  elbows  against 
the  lower  ribs, 

36 


562  ABNORMAL   LABOR. 

Lahorde^s  method — rhythmic  pulling  forward  of  tlie  tongue — has 
been  praised  as  effective  when  everything  else  had  failed.  I  have 
no  personal  experience  with  it  in  new-born  children,  but  in  anaes- 
thesia asphyxia  in  grown-up  people  it  has  seemed  to  me  to  be  better 
than  anything  else. 

Some  practise  insufflation  simply  by  laying  a  cloth  over  the  child's 
mouth  and  blowing  through  it.  When  I  have  tried  this  method, 
the  air  went  into  the  stomach ;  and  I  prefer,  therefore,  the  use  of 
the  catheter. 

If  a/arac/ic  battery  is  at  hand,  it  should  be  used.  Some  look  upon 
it  as  the  best  of  all  means  to  overcome  asphyxia.  One  pole  should 
be  placed  above  the  coDar-bone,  between  the  sternocleidomastoid 
and  trapezius  muscles.  This  is  done  in  the  hope  of  reaching  the 
phrenic  nerv^e.  The  other  electrode  should  be  placed  at  the  edge  of 
the  ribs  on  the  right  side.  The  idea  of  this  is  to  irritate  the  dia- 
phragm to  contraction  and  to  avoid  the  heart.  If  the  phrenic  nerve 
is  irritated  it  ^^'ill  make  the  diaphragm  contract,  and  thus  powerfully 
attract  air  into  the  lungs.  But  the  pneumogastric  nerve  is  found  in 
the  same  cervical  triangle,  and  the  irritation  of  that  nerve  would 
make  the  heart-beats  slower,  and  might  thus  do  more  harm  than  good. 
Maybe  the  favorable  action  in  reality  is  only  due  to  the  powerful 
cutaneous  irritation  produced  by  the  current.  At  all  events  the  effect 
should  be  carefuDy  watched. 

Another  way  of  expelling  aspired  substances  from  the  lungs  be- 
sides those  mentioned  above — Schultze  swingmgs  and  aspiration — is 
to  suspend  the  child  by  the  feet  and  shake  it. 

In  the  pallid  variety  of  asphyxia,  when  life  is  nearly  extinct,  all 
movements,  especially  the  Schultze  method,  should  be  avoided,  and 
recourse  had  to  the  warm  bath,  rubbing,  insufflation,  and  electricity. 

After  deep  asphyxia  the  child  should  be  watched  carefully  for  sev- 
eral days,  in  order  to  come  to  its  assistance  if  needed.  As  a  routine 
treatment,  it  is  well  to  prescribe  brandy  and  digitalis,  5  drops  of  the 
former  and  1  drop  of  the  tincture  of  the  latter  every  2  to  4  hours.  It 
may  also  be  useful  to  place  the  child  in  an  incubator,  and  at  all  events 
it  should  be  kept  in  an  even,  warm  temperature  by  covering  it  well 
and  placing  hot-water  bottles  around  it. 

In  the  purple  variety,  some  advise  to  bleed  the  child  by  letting 
half  an  ounce  of  blood  escape  before  tying  the  navel-string,  while 
others  even  wait  several  minutes  before  they  tie  the  cord,  with  a  view 
of  giving  the  child  most  of  the  blood  that  is  in  the  placenta.  Per- 
sonally, I  neither  do  one  nor  the  other.  As  to  bloodletting,  I  think  it 
is  superfluous.  The  congested  organs  can  be  depleted  by  attraction 
to  the  skin.  And  when  there  is  any  danger  of  the  child's  life, 
especially  in  the  pallid  form,  I  take  it  to  be  more  important  to  sever 


INJURY   TO    THE   FCETUS    DURING   LABOR.  563 

the  child  from  the  mother  and  begin  the  course  of  reviving  measures 
described  above. 

Wlien  there  is  the  sHghtest  sign  of  hfe,  especiahy  heart-beat,  or  of 
improvement  in  the  child's  condition  by  treatment,  we  should  con- 
tinue our  efforts  to  revive  it  fully.  The  writer  has  himself  worked 
for  two  and  a  half  hours  on  an  asphyctic  child  before  it  made  the 
first  respiratory  gasp,  and  others  state  also  that  children  have  been 
revived  although  they  did  not  breathe  for  two  or  three  hours. 

§  3.  The  Avulsion  of  the  Head  of  the  PcBtus. — The  avulsion 
and  retention  of  the  fetal  head  in  the  cavity  of  the  uterus  constitutes 
one  of  the  most  serious  complications  of  childbirth.  Macerated  or 
immature  foetuses  are  more  liable  to  this  injury  than  those  who  are 
full-born  and  alive. 

Matthews  Duncan  found  experimentally  that  the  spine  gave  way 
at  a  traction  of  105  pounds,  and  the  head  became  totally  severed  from 
the  body  when  the  weight  reached  120  pounds. 

In  most  cases  this  accident  is  due  to  narrowness  of  the  pelvis  or 
to  enlargement  of  the  head,  particularly  from  hydrocephalus.  But 
frequently  the  event  is  attributable  to  errors  on  the  part  of  the 
accoucheur,  who  in  some  cases  was  neither  a  physician  nor  a  mid- 
wife, but  the  husband  of  the  patient,  or  some  other  man  or  woman, 
sometimes  several  joining  their  forces  in  order  to  extract  the  child. 

In  regular  obstetric  practice,  avulsion  is  most  likely  to  happen 
during  extraction  after  podalic  version.  If  the  chin  is  allowed  to  be 
hooked  over  the  symphysis  pubis,  or  if  in  occipito-anterior  positions  no 
means  are  used  for  making  the  head  pass  through  the  pelvis  with 
favorable  diameters,  and  then  great  force  is  used  in  hauling  on  the 
shoulders,  the  head  cannot  fail  to  be  torn  off.  In  the  operation  of 
decapitation  in  neglected  transverse  presentation,  the  head  is  on  pur- 
pose severed  from  the  body  in  order  to  accomplish  delivery. 

The  head  remaining  in  the  uterus  has  been  expelled  by  uterine 
contraction.  It  has  suppurated  and  become  disintegrated,  or  has  given 
rise  to  general  sepsis  and  death.  The  sharp  edges  of  the  bones  have 
burrowed  into  the  neighboring  tissues,  causing  vesicovaginal  and 
rectovaginal  fistulae. 

The  removal  of  the  torn-off  head  has  sometimes  proved  exceed- 
ingly difficult,  even  in  the  hands  of  the  most  experienced  obstetricians. 
Special  instruments  have  been  devised  for  the  purpose,  all  of  which 
have  proved  more  or  less  unsatisfactory.  Delivery  has  been  accom- 
plished in  the  most  different  ways, — manual  extraction,  forceps,  cepha- 
lotribe,  cranioclast,  symphyseotomy,  Caesarean  section,  amputation  of 
the  uterus,  and  removal  of  detached  bones  through  the  vagina,  the 
rectum,  or  the  abdominal  wall. 

The  death-rate  in  these  operations  has  been  over  twenty  per  cent. 


564  ABNORMAL   LABOR. 

In  some  cases  it  was  due  to  rupture  of  the  uterus,  in  otliers  to  hem- 
orrhage without  rupture,  and  in  most  to  sepsis,  in  which  respect  it 
should,  however,  be  noticed  that  most  of  these  cases  occurred  in 
private  practice,  and  without,  or  with  insufficient,  antiseptic  precau- 
tions. 

Treatment. — If  there  is  no  mechanical  disproportion  between  the 
head  and  the  pelvis,  it  may  be  possible  to  expel  it  by  pressure  from 
above,  or  to  extract  it  manually  by  passing  two  fmgers  into  the  mouth 
and  the  thumb  into  the  foramen  magnum  and  taking  care  to  conduct 
the  mento-occipital  diameter  through  the  axis  of  the  pelvis.  If  this 
does  not  soon  succeed,  the  head  should  be  pressed  down,  perforated, 
and  extracted  with  cranioclast.  If  this  instrument  is  not  available, 
perhaps  the  head  may  be  extracted  with  forceps  after  having  been 
diminished  by  craniotomy.  Great  care  should  be  taken  to  place  the 
surroundings  of  the  foramen  magnum  so  that  no  sharp  bones  will 
wound  the  walls  of  the  parturient  canal  during  extraction. 

In  those  cases  in  which  the  soft  parts  of  the  neck  are  still  intact 
and  the  separation  is  limited  to  the  spine,  perforation  may  be  made 
through  the  dorsal  vertebrse  and  the  brain  broken  up  and  washed  out 
with  a  catheter,  when  the  head  may  be  extracted  manually  or  with 
the  forceps. 


PART   III.— OBSTETRIC   OPERATIONS. 

Several  obstetric  operations  have  already  been  fully  described  in 
connection  with  the  conditions  for  which  they  are  used.  Thus  the 
removal  of  the  placenta  by  expression  has  been  described  under  the 
management  of  normal  labor  (p.  196),  and  that  by  direct  separation 
and  extraction,  in  treating  of  the  retention  and  adhesion  of  the  placenta 
(p.  419).  Episiotomy  has  been  described  in  connection  with  means 
of  preventing  the  laceration  of  the  perineum  (p.  541).  Enucleation 
of  the  head  by  pressure  through  the  rectum  was  referred  to  under  the 
management  of  normal  labor  (p,  193),  and  more  fully  in  speaking  of 
the  prophylactic  treatment  of  laceration  of  the  perineum  (p.  541). 


CHAPTER   I. 

TAMPONADE. 


If  tamponade  is  decided  on,  it  should  be  effective.  To  put  three  or 
four  pieces  of  cotton  of  the  size  of  hen's  eggs  into  the  vagina  in  order  to 
check  a  hemorrhage  is  nugatory.  The  blood  will  soon  soak  through 
and  the  patient  be  in  the  same  danger  as  before.  Iodoform  gauze  is 
too  porous  a  material  to  form  a  reliable  antihemorrhagic  plug.  I  use 
it  only  in  case  there  is  a  partial  dilatation  of  the  cervical  canal.  Then 
I  fill  this  with  iodoform  gauze,  for  which  purpose  it  is  well  adapted  by 
its  softness.  A  pledget  of  iodoform  gauze  may  also  be  placed  at  the 
vault  of  the  vagina,  covering  the  os.  But  most  of  the  vagina  should 
be  filled  with  pledgets  of  absorbent  cotton  wrung  out  of  a  one  per 
cent,  emulsion  of  creolin,  which  has  both  antiseptic  and  haemostatic 
properties.  For  this  purpose  I  take  two  squares  of  cotton  of  the  full 
width  as  it  comes  from  the  factory  in  pound  packages,  that  is  to  say 
about  a  foot.  These  are  thoroughly  immersed  in  the  emulsion,  wrung 
out,  and  torn  lengthwise  into  shreds  about  two  inches  wide,  which  are 
folded  until  they  form  small  flat  squares.  The  patient  should  be 
placed  in  Sims's  position  and  a  Sims  speculum  introduced,  exposing 
the  OS.  After  having  removed  all  clots,  washed  the  vagina  with  cotton 
dipped  in  creolin  emulsion,  and  wiped  the  vagina  dry,  it  is  gradually 
filled,  beginning  at  the  top  with  one  on  either  side  of  the  cervix,  one 
in  front,  and  one  behind,  and  pressing  the  pledgets  with  a  strong 
dressing-forceps  until  the  whole  cavity  is  closely  packed  down  to  the 
entrance  of  the  vagina.     This    tampon    should    not  be  left  in  situ 

565 


566  OBSTETRIC    OPERATIONS. 

longer  than    twenty-four   hours,  and    should    very  exceptionally  be 
renewed. 

Before  proceeding  any  farther,  I  would  particularly  warn  against 
dipping  the  cotton  used  for  the  tampon  in  liquor  ferri  chloridi.  Its 
removal  costs  the  patient  great  pain,  and  I  have  seen  an  ulcer  pro- 
duced by  it  which  took  three  weeks  to  heal.  The  liquor  ferri  chloridi 
is  so  strong  a  preparation  that  it  should  not  be  used  on  a  tampon 
unless  diluted  with  at  least  ten  times  as  much  water.  I  have  also 
seen  the  whole  vaginal  epithelium  come  off  in  one  piece  like  a  fmger- 
cot  after  the  use  of  the  injection  of  one  teaspoonful  to  a  pint  of  water. 
For  injection  the  strength  should  not  exceed  half  a  teaspoonful  to 
a  pint,  or  about  one  per  cent.,  most  teaspoons  holding  nearly  two 
fluidrachms  (eight  cubic  centimetres). 


CHAPTER   II. 
ARTIFICIAL   DILATATION   OF   THE    CERVIX   DURING   PREGNANCY. 

To  USE  tents  for  the  dilatation  of  the  cervix  is  not  to  be  recom- 
mended, since  it  is  very  difficult,  or  next  to  impossible,  to  obtain  them 
in  an  aseptic  condition,  and  the  process  of  imbibition  is  slow.  Rapid 
dilatation  by  means  of  coniform,  olive-shaped,  and  expanding  dilators 
is  much  to  be  preferred.  Hanks's  dilators  (Fig.  402)  are  usuahy  made 
of  hard  rubber  and  lose  their  curvature  if  boiled.  Instead,  they  may 
be  disinfected  by  immersion  for  five  minutes  in  a  solution  of  bichloride 
of  mercury  (1  :  1000),  lysol,  or  creolin  (1  :  100),  or  they  may  be  made 
of  metal.  They  are  numbered  from  9  to  20,  which  numbers  indicate 
the  circumference  in  millimetres. 


Hauks's  cervical  dilator.    A,  stem;  B,  shoulder;  (,',  point. 

When  the  coniform  dilators  meet  with  resistance,  they  are  ex- 
changed for  the  expanding  instrument,  working  on  the  principle  of  a 
glove-stretcher, — that  is,  by  lateral  expansion  effected  by  separating 
metal  rods  from  one  another.  Of  the  numerous  instruments  of  this 
class  that  of  Goelet  (Fig.  403)  is  particularly  well  adapted  for  abortion 
cases,  on  account  of  having  four  long  and  strong  branches. 

I  have  had  a  series  of  ten  olive-shaped  hard-rubber  balls  made 
measuring  from  33  to  67  millimetres  in  circumference,  and  marked 
according  to  the  American  scale  as  Nos.  22,  25,  28,  31,  34,  37,  39,  41, 


ARTIFICIAL  DILATATION  OF  THE  CERVIX  DURING  PREGNANCY.      567 

43,  and  45.  They  can  be  screwed  on  an  S-shaped  metal  shaft.  The 
largest  serves  as  a  handle  (Fig.  404).  These  olives  give  all  the  dilata- 
tion needed  to  introduce  the  index-finger  and  a  large  curette  into  the 
uterine  cavity.  If  still  more  space  is  needed,  as  in  premature  labor, 
there  is  a  similar  set  of  ten  balls  devised  by  Hanks.  They  range  from 
73  to  137  millimetres  in  circumference,  and  cause  sufficient  dilatation 
for  the  passage  of  a  large  foetus. 

Fig.  403. 


Goelet's  expanding  dilator.    A,  rack  ;  B,  set-screw  ;  C,  articulation  of  the  fourth  branch. 


Modus  Operandi. — The  patient  is  placed  in  the  dorsal  position.  In 
hospitals  she  is  placed  on  a  special  operating-table,  such  as  Edebohls's, 
Boldt's,  or  Cleveland's,  which  have  attachments  for  lifting  the  feet  up 
in  stirrups.  In  private  practice  any  stout  table  may  be  used,  preferably 
a  common  kitchen  table,  measuring  four  feet  in  length  and  two  in  width. 
It  should  be  covered  with  a  folded  quilt  and  a  pillow  for  the  head. 
To  the  quilt  is  pinned  a  sheet  of  rubber  or  enamel,  an  inexpensive 
kind  of  oil-cloth  much  used  for  table-covers.  The  lower  flap  of  this 
cloth  is  pinned  together  so  as  to  form  a  funnel  leading  to  a  slop-pail 
between  the  feet  of  the  operator.     On  the  top  of  the  water-proof 

Fig.  404. 


Garrigues's  olive-shaped  cervical  dilators. 


material  comes  a  folded  sheet,  on  Avhich  the  patient  lies,  her  buttocks 
protruding  three  or  four  inches  from  the  end  of  the  table.  "While  she 
is  being  anaesthetized,  her  feet  may  rest  on  the  seat  of  the  chaii'  later 
occupied  by  the  obstetrician.  When  she  is  under  the  influence  of  the 
aneesthetic,  her  genitals  are  shaved  and  the  abdomen  disinfected  with 
tinctura  saponis  viridis,  bichloride  of  mercury,  and  alcohol,  as  de- 
scribed above  (pp.  188,  190,  218).  The  vagina  is  disinfected  by  pour- 
ing the  soap  tincture  into  it  and  scrubbing  it  with  cotton  balls  or 
gauze,  using  a  copious  amount  of  sterilized  water,  and,  finally,  lysol. 


568 


OBSTETRIC    OPERATIONS. 


When  the  patient  is  properly  ansesthetized,  disinfected,  and 
catheterized,  her  legs  are  forcibly  bent  in  the  hip-joints,  so  as  to  bring 
her  knees  high  up  towards  the  shoulders,  in  which  position  they  are  held 
by  Robb's  leg-holder  (Fig.  405).  It  consists  of  a  long,  narrow  band 
with  rings  and  snaps.  It  is  easily  rolled  together  and  takes  up  little 
space  in  the  satchel.  It  surrounds  the  lower  part  of  the  thigh,  passes 
under  the  right  shoulder  and  above  the 
left,  wdiich  is  protected  against  pressure  ^^^'-  ^06. 

by  a  thick  pad  of  cotton  batting  placed 
between  it  and  the  leg-holder. 

Next,  Garrigues's  self-holding  weight 


Fig.  405. 


Robb's  leg-holder. 


Garrigues's  weight  speculum. 


speculum  (Fig.  406)  or  a  single-bladed  Sims  speculum  is  placed  on 
the  posterior  wall  of  the  vagina.  An  anterior  blade  or  any  kind  of 
vagmal  retractor  may  also  be  needed  (Fig.  407).     The  cervical  por- 


FiG.  407. 


Schroeder's  vaginal  retractor. 


tion  of  the  uterus  is  seized  at  the  right  side  of  the  os  with  a  bullet- 
forceps  and  pulled  down  to  the  vaginal  entrance.    In  using  the  thicker 


CURETTAGE. 


569 


cone-shaped  and  all  the  olive-shaped  dilators,  counter-pressure  should 
be  exerted  on  the  fundus  of  the  uterus  by  an  assistant. 

During  the  first  three  months  of  pregnancy,  the  cone-shaped  and 
expanding  dilators  suffice,  but  from  the  fourth  month  the  ohve- 
shaped  are  required. 


CHAPTER   III. 
CURETTAGE. 


For  emptying  the  uterus  in  abortion  cases  and  sometimes  after 
delivery,  some  scraping  instrument  may  be  needed.  At  a  very  early 
stage  of  pregnancy,  say  at  the  end  of  the  first  month,  Sims's  sharp 


Fig.  408. 


Sims's  sharp  curette. 


curette  (Fig.  408)  or  Simon's  sharp  spoon-shaped  curette  (Fig.  409) 
may  be  employed.     During  the  second  month  Recamier's  dull  curette 


Fig.  409. 


Simon's  sharp  curette. 


(Fig.  410)  is  quite  useful.     From  the  third  month  to  the  end  of  preg- 
nancy Thomas's  large  dull  wire  curette  (Fig.  411),  with  an  inflexible 


Fig.  410. 


R6camier's  dull  curette. 


shank  and  an  eye  large  enough  to  admit  the  tip  of  the  forefinger,  is  an 
admirable  instrument,  both  for  the  purpose  of  loosening  the  ovum 


Fig.  411. 


Thomas's  large  dull  wire  curette. 


from  the  walls  of  the  uterus  and  for  removing  it  by  seizing  it  between 
the  instrument  and  the  index-finger. 


570 


OBSTETRIC    OPERATIONS. 


How  much  the  cervix  can  be  dilated  depends,  of  course,  chiefly  on 
its  size.  A  small  uterus  ^^ill  only  admit  the  curette.  A  somewhat 
larger  one  allows  us  to  use  the  finger  as  a  curette  by  seizing  the  uterus 
from  above  and  pressing  it  down  on  the  index-finger  introduced 
through  the  vagina,  but  often  the  ovum  is  inserted  so  high  up,  right  on 
the  fundus,  that  we  cannot  detach  it  with  the  finger-nail,  but  must 
have  recourse  to  a  curette  anyhow,  and  at  all  events  the  finger  cannot 
remove  the  decidua  vera.     From  the  third  month  there  is  mostly  room 

Fig.  412. 


Placenta-forceps  witli  heart-shaped  jaws. 


for  the  finger  and  the  large  dull  wire  curette,  which  work  well  together, 
the  finger  being  pressed  against  the  hole  in  the  curette  with  part  of  the 
tissue  to  be  removed  caught  between  the  two.  For  the  removal  of 
the  fffitus  a  blunt  forceps  with  heart-shaped  or  oval  rings  (Figs.  412, 
413)  may  be  required,  and  in  rare  cases  the  same  instrument  may  be 
needed  in  removing  the  placenta,  but  in  nearly  all  cases  I  prefer  the 
combined  use  of  the  finger  and  the  large  curette. 

If  for  some  reason  no  anaesthetic  is  used,  one  obtains  better  access 
to  the  interior  of  the  uterus  by  placing  the  patient  in  Sims's  position 
without  pulling  the  uterus  down.     When  the  scraping  is  finished,  the 


Fig.  413. 


Placenta-forceps  with  oval  jaws. 

patient  is  turned  back  to  the  dorsal  position,  which  is  both  more  con- 
venient and  safer  than  the  lateral  during  irrigation. 

It  is  not  possible  to  tell  how  much  scraping  should  be  done.  The 
obstetrician  must  have  in  view  that  the  pregnant  uterus  is  much  softer 
than  the  unimpregnated,  and  that  the  danger  of  perforating  it  is  greater. 
Scraping  should  only  be  done  by  moving  the  curette  from  the  fundus 
to  the  OS,  or  laterally  along  the  fundus  or  along  the  walls  of  the  corpus, 
never  from  below  upward.     In  a  general  way  it  may  be  stated  that 


CURETTAGE.  571 

9 

when  moderate  force  is  used,  it  is  safe  to  scrape  as  long  as  anything 
comes  off.  What  is  to  be  removed  is  the  foetus,  the  ovum,  and  the 
decidua  vera,  as  far  as  it  comes  off  easily.  It  forms  a  spongy  mass, 
easily  recognized  when  once  seen.  In  a  case  of  abortion  after  double 
ovariotomy  at  two  and  a  half  months  I  curetted  after  the  foetus  was 
expehed  and  the  ovum  which  lay  loose  in  the  vagina  had  been 
removed,  and  scraped  off  four  or  five  times  as  much  tissue  as  that 
forming  the  ovum.^  On  Braune's  beautiful  plate  representing  a  sec- 
tion of  the  frozen  body  of  a  woman  at  the  end  of  the  eighth  week  of 
pregnancy,^  the  decidua  in  the  lower  part  of  the  uterine  cavity  is  half 
an  inch  in  thickness  and  the  area  of  its  cut  surface  is  twice  as  large  as 
that  of  the  chorion. 

Immediately  before  and  after  the  curettage  the  uterine  cavity 
should  be  flushed  with  two  pints  of  a  one  per  cent,  emulsion  of 
creolin,  for  which  purpose  I  prefer  a  single-current  metal  tube  (Fig. 
414)  fastened  by  means   of  a   flange  to    the  tubing   of  a   fountain 

Fig.  414. 


Garrigues's  single-current  soft-metal  intra-uterine  tube. 

syringe.  The  bag  is  suspended  about  three  feet  over  the  table.  It  is 
sometimes  practicable  to  fasten  it  to  a  gas-fixture  or  the  knob  on  the 
blinds,  or  a  nail  driven  into  the  window-frame,  or  have  it  held  by  an 
assistant ;  but  since  you  cannot  count  on  finding  either,  it  is  well  to 
carry  a  screw-hook  in  your  satchel,  which  is  easily  screwed  into  any 
Avoodwork. 

The  object  of  the  preliminary  irrigation  is  to  remove  blood,  mucus, 
and  some  of  the  germs  that  may  have  found  their  way  into  the  uter- 
ine cavity ;  that  following  the  curettage  serves  to  remove  debris  and 
arrest  hemorrhage.  If  a  rather  free  hemorrhage  continues  after  the 
irrigation,  I  pack  the  uterus  with  iodoform  gauze  and  then  the  vagina 
with  cotton  pledgets  wrung  out  of  creolin  emulsion  as  described 
above.  If  there  is  little  or  no  hemorrhage,  I  use  only  the  vaginal 
plug  and  no  intra-uterine  packing.  The  vaginal  packing  is  removed 
the  next  day,  the  intra-uterine  is  gradually  withdrawn  and  cut  short 
on  the  third  and  fourth  day,  and  finally  removed  on  the  fifth  or  sixth. 
During  these  days  the  vagina  is  only  filled  quite  loosely  with  iodoform 
gauze,  which  being  in  touch  with  the  intra-uterine  gauze  serves  as  a 
drain.     After  all  has  been  removed  the  vagina  is  irrigated  twice  a  day 

^  Garrigues,  "A  Case  of  Double  Ovariotomy  durini,'  Pregnancy,"  The  Clinical 
Recorder,  vol.  i.,  No.  2,  p.  49,  April,  1896. 

^  Willielm  Braune,  Topographisch-anatomischer  Atlas,  Leipsic,  1875,  Plate  II. 


572  OBSTETRIC    OPERATIONS. 

with  creolin  or  some  other  antiseptic,  as  long  as  there  is  any  dis- 
charge. If  no  intra-uterine  packing  is  used,  this  vaginal  irrigation 
may  be  instituted  the  day  the  vaginal  plug  is  removed. 

When  the  uterus  has  been  emptied  and  the  tampon  applied,  I 
give  a  drachm  (4  grammes)  of  the  fluid  extract  of  ergot,  three  times  a 
day,  until  an  ounce  has  been  used  in  all.  If  the  patient  has  any  pain, 
there  is  no  objection  to  the  administration  of  an  opiate  ;  but,  as  a 
rule,  all  pain  ceases  after  the  removal  of  the  vaginal  plug.  The  reader 
may  therefore  ask  Avhy  I  put  it  in.  In  hospital  practice  it  may  be 
dispensed  with  if  there  is  no  bleeding,  because  in  case  hemorrhage 
came  on  later,  the  house  surgeon  could  check  it  by  tamponing ;  but 
in  private  practice  it  is  safer  to  tampon  the  vagina  for  the  first  twenty- 
four  hours  after  the  curettage.  The  patient  is  kept  in  bed  for  a  week, 
and  in  her  room  for  another.  If  the  abortion  was  caused  by  retro- 
flexion, this  should  be  treated  during  the  after-treatment. 

From  the  end  of  the  fifth  month  the  child  may  be  born  alive, 
inasmuch  as  its  circulation  may  be  maintained  independently  of  the 
mother,  and  the  muscles  evidence  contractility  ;  but  at  this  early  period 
it  is  not  viable.  If  the  placenta  is  expelled  spontaneously,  or  ex- 
pressed by  Crede's  method,  which  is  often  possible. at  this  stage,  the 
case  should  be  regarded  as  one  of  premature  labor,  and  the  treatment 
recommended  for  abortion  is  not  indicated. 

If  pregnancy  is  terminated  after  the  end  of  the  fifth  month,  and  the 
placenta  is  not  expelled  either  by  uterine  contraction  or  expression, 
it  is  better  to  tampon  the  uterus  and  vagina  and  await  further  devel- 
opments. If  the  placenta  does  not  come  away  within  twenty-four 
hours,  the  dressing  should  be  removed  and  a  new  one  left  in  place 
a  day  longer ;  but  if  the  placenta  does  not  come  off  in  two  days,  its 
mechanical  removal  is  urgent. 


CHAPTER   IV. 
INDUCTION    OF   PREMATURE   LABOR. 

Labor  may  be  induced  in  many  ways,  but  some  of  them  have 
proved  vastly  superior  to  others  in  regard  to  efficiency,  safety,  and 
expeditiousness.  While  the  obstetrician  always  can  perform  arti- 
ficial abortion,  it  is  not  so  with  the  induction  of  premature  labor. 
Here  the  collaboration  of  nature  is  an  absolute  requisite  and  must  be 
sohcited.  We  can  do  much  to  help  nature,  but  the  one  thing  we  must 
await  from  her  side  is  the  contraction  of  the  muscular  wall  of  the 
uterus — without  uterine  contraction,  no  labor.  In  cases  in  which 
there  is  no  particular  hurry,  it  is  well  first  to  use  repeated  vaginal 


INDUCTION    OF    PREMATURE    LABOR. 


573 


douches  with  hot  water,  or  alternately  with  hot  and  cold  water.  As 
much  as  two  or  three  gallons  of  sterilized  water  should  be  injected. 
If  necessary,  this  may  be  followed  by  the  application  of  a  vaginal 
tampon.  Under  these  circumstances  it  should  be  removed,  and,  if 
necessary,  renewed  every  six  hours. 

Both  these  methods,  however,  have  the  drawback  that  they  im- 
pair the  epithelium  of  the  vagina,  and  may  be  dispensed  with  if  a 
bougie  can  be  introduced  into  the  cavity  of  the  uterus.  For  this  pur- 
pose we  choose  an  English  bougie  No.  10,  the  French  being  too  flexible. 
First,  the  bougie  is  disinfected  by  immersion  for  ten  minutes  in  a  solu- 
tion of  bichloride  of  mercury  (1  :  1000)  and  lubricated  with  boiled 
g'lycerin  with  or  without  the  addition  of  corrosive  sublimate  (1  :  1000). 
The  varnish  of  the  bougies  is  destroyed  by  carbolic  acid,  creolin,  or 
lysol,  which  substances  therefore  should  be  avoided.  We  should  use 
bougies,  not  catheters,  in  order  to  avoid  admission  of  air  to  the  uterine 
cavity,  and  they  ought  to  be  introduced  without  stylet,  as  this  makes 
them  too  stiff  and  prevents  them  from  sliding  aside  when  they  meet 
an  obstacle.  The  lower  numbers  of  bougies  are  too  flexible,  while 
No.  10  has  given  perfect  satisfaction 
in  the  writer's  hand.  Fig.  415. 

The  patient's  vagina  should  be 
disinfected  as  described  (p.  565), 
and  then  she  should  be  turned  over 
into  Sims's  position,  which  facili- 
tates the  introduction  of  the  bougie 
very  much.  The  os  is  exposed  with 
Sims's  speculum,  and  the  cervix 
seized  with  a  bullet-forceps.  The 
placenta  being  commonly  inserted 
on  the  anterior  or  the  posterior  wall 
of  the  uterus,  it  is  better  to  intro- 
duce the  bougie  at  one  of  the  sides. 
If  it  meets  with  any  resistance,  it  is 
twirled  a  little  between  the  fingers, 
when  often  it  slides  in  without  fur- 
ther difficulty  ;  but  if  it  cannot  be 

pushed  in  deep  enough,  another  place  should  be  tried.  It  should  be 
pushed  in  to  its'  full  length,  with  the  exception  of  the  last  two  or  three 
inches,  which  are  bent  in  a  circle  at  the  vault  of  the  vagina  and  held 
in  position  with  a  pledget  of  iodoform  gauze. 

When  the  cervical  canal  is  sufficiently  dilated  to  admit  a  finger, 
tlie  bougie  may  be  removed  and  Robert  Barnes's  dilators  used  in- 
stead. These  consist  of  a  set  of  three  fiddle-shaped  rubber  bags, 
with  a  tube  of  the  same  material  (Fig.  415),  at  the  end  of  which  is 


Robert  Barnes's  cervical  dilators. 


574  OBSTETRIC   OPERATIONS. 

a  small  metal  tube  with  a  screw-thread  fitting  another  metal  tube, 
which  has  a  stopcock,  by  means  of  which  fluid  may  be  retained  in 
the  bag.  At  the  other  end  this  tube  fits  by  mere  apposition  a  third 
metal  tube,  which  at  its  other  end  has  a  screw  fitting  a  Davidson 
syringe  No.  1.  This  may  appear  complicated  to  the  reader,  but  in 
practice  it  is  very  simple,  and  this  metal  attachment,  consisting  of 
three  pieces,  is  a  great  improvement.  On  the  side  of  the  bag  is  often 
found  a  little  pouch,  which  is  meant  to  give  admission  to  the  tip  of 
a  uterine  sound,  with  which  the  bag  should  be  introduced  into  the 
uterus.  But  this  method  is  greatlv  inferior  to  the  use  of  a  curved 
forceps  (Fig.  416).  The  sound  is  apt  to  tear  the  pouch,  w-hich  by  its 
projection  increases  the  friction  against  the  walls  of  the  cervical  canal, 
and  serves  as  a  receptacle  for  dirt  hard  to  dislodge.  When  undilated 
the  bags  measure  from  li  to  2^  inches  (from  3  to  6  centimetres)  at 
the  narrowest  part ;  but,  on  account  of  their  elasticity,  when  fully 
dilated,  they  measure  4,  5,  and  7  inches  (from  10  to  18  centimetres) 
ill  circumference  respectively.  They  may  be  boiled  with  soda  solu- 
tion (p.  186)  and  be  made  slippery  with  lysol  or  creolin  emulsion. 

Fig.  416. 


Forceps  for  carrying  rubber  bags  or  gauze  into  the  uterus. 

In  order  to  introduce  them  they  should  be  folded  lengthwise  and 
seized  with  the  forceps.  The  patient  should  be  placed  in  Sims's 
position,  and  the  operator  should  place  his  left  forefinger  on  the  os 
and  slide  the  forceps  with  the  bag  along  the  volar  surface  of  the 
finger.  The  bag  should  be  introduced  so  deep  that  its  distal  end 
rests  above  the  internal  os,  the  proximal  end  in  the  vagina,  and  the 
thinner  middle  part  in  the  cervical  canal.  When  it  is  in  place,  it 
is  slowly  filled  with  lysol  solution  (1  :  100)  or  sterilized  water. 
When  it  is  fully  dilated  it  may  be  withdrawn  without  emptying  it, 
and  the  next  size  introduced  in  its  place.  The  action  of  these  cer- 
vical bags  may  be  intensified  by  placing  a  larger,  more  cylindrical  bag 
in  the  vagina, — a  so-called  colpeurynter  (Fig  417),  The  object  of  the 
dilators  is  indeed  not  only  to  obtain  space  for  the  passage  of  the 
child,  but  to  call  forth  uterine  contraction  by  reflex  action.  Some- 
times we  do  not  succeed  in  this,  even  after  full  dilatation  with  Barnes's 
dilators.  Then  the  larger  and  unyielding  coniform  bag  of  Champetier 
de  Ribes  (Fig.  418),  made  of  stout  silk,  covered  with   rubber,  and 


INDUCTION    OF   PREMATURE   LABOR. 


575 


having  a  diameter  of  4  inclies  (10  centimetres)  at  tlie  base,  may  be 
substituted.  It  is  used  in  the  same  way  as  Barnes's  dilators,  but 
placed  just  above  the  internal  os  in  the  lower  uterine  segment.  It  is 
introduced  with  a  forceps  made  for  the  purpose  (Fig.  419),  but  this 


Ftg.  417. 


Peterson's  colpeuiynter. 


may  also  be  accomplished  with  the  smaller  instrument  used  for  carry- 
ing Barnes's  dilators  or  gauze  into  the  uterus  (Fig.  416).  It  may  be 
left  until  it  is  pushed  out  by  uterine  contraction,  or  this  action  may 
be  combined  with  a  pull  on  the  tube,  either  by  attaching  it  to  the  end 


Fig.  418. 


Champetiur  de  Kibe-s'is  iuulastic  cervical  dilator. 


of  the  bed,  or  making  a  connection  with  a  weight  of  from  one  to  four 
pounds  going  over  a  pulley,  or  simply  by  pulling  on  the  tube  with 
the  hand. 

If  the  other  two  methods — the  bougie  and  the  dilators — have  not 


576  OBSTETRIC    OPERATIONS. 

brought  on  labor-pains,  or  at  least  not  sufficiently  strong  ones,  the  bag 
of  waters  may  be  ruptured,  which  may  be  done  with  a  wire  stylet  or 
a  goose-quill  sliding  on  a  sound.  Many  use  this  method  from  the 
start,  and  if  there  is  an  over-distention  of  the  uterus,  which  prevents 
contractions,  this  is  the  way  to  be  preferred,  at  least  as  the  first  step, 
which  then  may  be  combined  with  other  methods,  according  to  cir- 
cumstances. This  method  should,  however,  as  a  rule,  only  be  used  if 
the  vertex  presents. 

I  shall  mention  another  method  invented  some  years  ago  and 
which  also  has  been  praised  in  this  country, — namely,  the  injection 
of  a  tablespoonful  of  sterile  glycerin  above  the  os  internum.  This 
procedure  was  based  on  the  great  attraction  for  water  possessed  by 
glycerin,  but,  cases  in  which  its  use  gave  rise  to  hsemoglobinuria  and 
chills  having  been  reported,  it  should  not  be  used. 

Finally,  the  application  of  the  constant  electric  current  has  been 

Fig.  419. 


Bag  in  grip  of  forceps. 

recommended.  The  positive  pole  is  placed  on  the  fundus,  the  nega- 
tive in  the  cervical  canal  or  on  the  vault  of  the  vagina.  At  first  weak 
currents  should  be  used,  and  with  intervals  like  normal  labor-pains. 
Electricity  is  undoubtedly  a  powerful  means  of  producing  muscular 
contraction,  but  it  would  seem  to  be  a  little  dangerous  for  the  foetus 
as  compared  with  the  three  methods  recommended  above. 

As  to  tents  we  refer  to  what  we  have  said  above  (p.  566). 
Hanks's  dilators  may  be  used,  but  on  account  of  their  stiffness  they 
are  apt  to  rupture  the  membranes.  If  this  happens,  and  the  foetus 
lies  in  cross  presentation,  we  should  try  to  save  as  much  licjuor  amnii 
as  possible  and  at  the  same  time  try  to  get  the  cervix  dilated  in  order 
to  be  enabled  to  turn  the  child.  On  the  other  hand,  if  there  is  a 
favorable  presentation  with  tendency  to  a  change  for  the  worse,  it  is 
well  to  rupture  the  membranes  early. 

In  whatever  way  labor  is  induced,  the  patient  has  to  be  watched 
almost  constantly.  In  some  cases  the  uterine  contractions  are  soon 
elicited  and  labor  progresses  rapidly  ;  in  others  it  takes  days. 


VAGINAL   AND    INTRA-UTERINE   INJECTIONS.  577 

CHAPTER    V. 

VAGINAL    AND   INTRA-UTERINE    INJECTIONS. 

In  hospitals  a  pail  of  glass  or  metal,  especially  agateware  or  other 
enamelled  metal,  is  used  as  a  reservoir  in  vaginal  and  intra-uterine 
injections.  In  priA'ate  practice  a  rubber  bag,  a  so-called  fountain 
syringe,  may  be  employed.  It  stands  boiling  in  soda  solution  (about 
two  per  cent.,  or  a  tablespoonfal  to  each  quart  of  water)  very  well. 
The  tube  used  for  irrigation  should  in  hospitals  be  of  glass.  For  the 
vagina  a  straight  tube  about  six  inches  long  is  used.  In  private  prac- 
tice, where  only  antisepsis  is  attempted,  the  nozzle  of  metal  or  hard 
rubber  which  comes  with  the  fountain  syringe  may  be  used.  For 
intra-uterine  injections  Garrigues's  glass  tube  should  be  used  (Fig. 
420).  It  is  made  of  thick  glass,  is  twelve  inches  long,  one  inch  in  cir- 
cumference, and  slightly  curved  like  a  male  catheter  near  the  distal 
end.  At  the  end  and  on  the  last  four  inches  are  distributed  nine 
openings.    In  order  to  adapt  it  easily  to  the  rubber  tube  of  the  foun- 

FiG.  420. 


Garrigues's  intra-uterine  glass  tube  with  attachment. 

tain  syringe  without  risk  of  breaking  the  glass  tube,  it  is  convenient 
to  have  a  short  piece  of  rubber  tubing  permanently  attached  to  it, 
and  at  the  other  end  one  of  those  short  glass  tubes  with  a  neck  near 
each  end  which  are  made  for  making  connections  and  are  found  in 
the  instrument  stores  (Fig.  420). 

In  order  to  protect  the  long  glass  tube  against  breakage,  I  carry  it 
in  a  case,  which  is  made  of  two  thin  wooden  arm-splints  a  foot  long 
lined  with  canton  flannel  and  held  together  with  a  bag  of  muslin  fit- 
ting them  tightly.  In  this  same  case  finds  also  room  a  wire  with  a 
hook  near  its  end  used  for  cleaning  the  tube  by  means  of  a  bit  of 
absorbent  cotton.  The  tube  may  be  boiled  immediately  before 
using  it. 

During  an  injection  the  patient  should  occupy  the  dorsal  position 
with  bent  knees.  She  may  be  placed  on  a  metal  douche-pan  (Fig. 
217,  p.  181)  or  she  may  be  pulled  so  far  over  the  edge  of  her  bed 
that  one  leg  rests  on  a  chair.     A  rubber  sheet  or  oil-cloth  is  placed 

37 


578  OBSTETRIC    OPERATIONS. 

under  her  nates,  and  made  to  form  a  gutter  descending  from  the  geni- 
tals into  a  slop-pail.  The  patient  may  be  placed  also  across  the  bed 
^vith  the  buttocks  passing  the  edge,  or  she  may  be  at  the  end  of  a 
table.  In  either  case  she  lies  on  a  rubber  sheet  or  oil-cloth,  which 
is  pinned  with  two  pins  so  as  to  form  a  funnel  leading  the  recurrent 
fluid  into  a  vessel  placed  on  the  floor.  Whatever  the  patient  lies  on 
— pan,  table,  or  bedstead — should  be  properly  padded,  so  as  to  avoid 
the  pain  of  pressure  against  a  hard  surface. 

The  jluids  to  be  used  are  plain  sterilized  water,  normal  salt  solu- 
tion, or  a  one  per  cent,  solution  of  creolin  or  lysol.  Rarely  less  than 
two  or  three  pints  are  used,  and  sometimes  much  more.  In  private 
practice  there  is,  as  a  rule,  no  difficulty  about  obtaining  hot  water,  but 
there  is  no  sterilized  cold  water  on  hand.  In  order  to  have  it  for 
operative  purposes,  it  is  well,  at  the  beginning  of  labor,  to  boil  several 
quarts  and  let  it  cool  off  covered. 

The  temperature  of  the  fluid  varies  from  being  lukewarm  to  be- 
ing decidedly  hot  (110-115-120°  F.),  which  latter  has  considerable 
haemostatic  power. 

Before  giving  any  kind  of  injection,  the  physician  or  nurse  disin- 
fects his  or  her  hands  and  spreads  the  disinfected  vulva  open.  For  a 
vaginal  injection  the  tube  is  inserted  up  to  the  vaginal  roof  and  car- 
ried all  around  the  cervix,  so  as  to  have  every  part  of  the  vagina  well 
bathed  with  fluid. 

In  the  beginning  of  the  antiseptic  era  I  used  a  1  :  2000  solution 
of  bichloride  of  mercury  for  vaguial  and  mtra-uterine  injections,  and 
later  a  1  :  4000 ;  but  I  soon  convmced  myself  of  their  danger  and 
substituted  creolin,  1  :  100,  for  vagmal  and  intra-uterine  douches.  As 
stated  above  (p.  550),  I  collected  from  literature  twenty  fatal  cases  of 
mercurial  poisoning  in  obstetric  practice  alone  and  added  two  from 
my  own  practice.  Since  then  I  have  exclusively  used  for  injection 
creolm  or  lysol. 

The  symptoms  that  have  been  observed  in  cases  of  poisoning  vnth 
corrosive  sublimate  used  in  vaginal  and  intra-uterine  mjections  are : 

The  alimentary  canal.  Thu'st,  foul  breath,  metallic  taste,  red  or 
bluish  color  and  swelling  of  the  gums ;  redness,  ulceration,  and 
sloughing  of  different  parts  of  the  mucous  membrane  of  the  buccal 
cavity  ;  deep  ulcers  in  the  tonsils ;  soreness  and  looseness  of  the 
teeth,  and  sometimes  salivation  ;  vomitmg,  abdominal  pain,  tenesmus ; 
profuse,  offensive,  often  bloody  diarrhoea.  The  fseces  contain  mer- 
cury. It  has  been  found  in  numerous  cases  after  vaginal  or  intra- 
uterine injection  of  a  solution  of  1  :  3000,  followed  by  the  injection 
of  plain  water,  and  even  afl:er  1  :  4000.  In  the  majority  of  cases  it 
is  found  in  the  fseces  already  the  next  day,  and  it  is  still  found  a  long 
time  after  discontinuing  the  use  of  the  bichloride. 


VAGINAL   AND    INTRA-UTERINE    INJECTIONS.  579 

The  tiropoietio  system.  There  is  a  marked  diminution  in  the  amount 
of  the  urine,  rising  to  absolute  suppression  of  the  secretion.  The 
urine  is  dark,  grumous,  contains  much  albumin,  mercury,  epithelial 
cells  from  the  kidneys,  and  hyaline  and  granular  casts. 

The  skin  is  often  covered  with  perspiration ;  it  has  been  found 
hyperaesthetic,  itching,  pale,  or  erythematous.  Sometimes  there  is 
considerable  swelling  of  the  subcutaneous  tissue. 

The  nervous  system.  In  the  beginning  the  patient  is  restless,  and 
suffers  from  insomnia  ;  later  she  becomes  drowsy,  sometunes  de- 
lirious, and  finally  she  collapses.  In  some  cases  spasmodic  twitch- 
ing or  cataleptic  stiffness  has  been  observed  in  the  extremities.  The 
pupils  are  sometimes  contracted  as  in  opium  poisoning.  Occasionally 
there  is  a  choking  sensation. 

The  pulse  is  rapid  and  weak,  the  temperature  subnormal. 

Of  these  symptoms  the  most  characteristic  are  the  diarrhoea,  the 
diminution  or  suppression  of  the  urinary  secretion,  the  stomatitis,  the 
low  temperature,  and  the  presence  of  mercury  in  the  stools  and  the 
urine,  as  proved  by  chemical  analysis. 

The  chief  changes  found  after  death  are  hemorrhagic  infiltration 
and  extensive  ulceration,  sorrietimes  diphtheritic  patches  and  sloughs 
of  the  large  intestine.  In  some  cases  a  lower  degree  of  inflamma- 
tion is  found  in  the  ileum.  Exceptionally  the  oesophagus  was  inflamed, 
and  in  some  cases  there  was  local  peritonitis.  The  mouth  and  throat 
are  the  seat  of  the  above-mentioned  changes. 

Another  constant  affection  is  parenchymatous  nephritis.  Some- 
times deposits  of  phosphate  or  carbonate  of  calcium  are  found  in  the 
convoluted  or  straight  tubules  ;  but  these  calcareous  deposits  are  often 
absent,  and  may,  on  the  other  hand,  be  found  under  different  circum- 
stances. In  some  cases  the  substance  of  the  brain  was  dry ;  in  others 
there  were  extravasations  of  blood  in  the  meninges. 

Cai^bolie  acid  endangers  life  and  health  much  the  same  as  corro- 
sive sublimate,  and  it  is  not  so  effective  as  an  antiseptic.  Carbolism 
is  characterized  by  the  sudden  loss  of  consciousness,  convulsions,  and 
death  in  coma.  A  solution  of  two  per  cent,  has  experimentally  been 
proved  to  possess  rather  weak  antiseptic  properties,  which  is  corrobo- 
rated by  abundant  clinical  experience ;  and,  on  the  other  hand,  the 
patient  cannot  stand  a  stronger  solution.  The  daily  use  of  this  drug 
is  also  very  irritating  for  doctors  and  nurses.  The  skin  cracks  and 
smarts,  the  fingers  become  numb,  there  is  a  very  disagreeable  sensa- 
tion of  cold  in  the  hands,  and  the  whole  nervous  system  is  affected 
by  it.  Its  odor,  especially  when  mixed  with  lochial  discharge,  is 
unpleasant  and  tenacious. 

CreoUn  is  an  excellent  antiseptic,  and  so  httle  poisonous  that  it 
can  be  taken  internally  in  the  dose  of  half  a  drachm  (2  grammes) 


580  OBSTETRIC   OPERATIONS. 

or  more  three  times  a  day  without  any  bad  effect.  Up  to  three  per 
cent,  the  emulsion  is  very  pleasant  to  the  skin.  It  makes  all  surfaces 
with  which  it  comes  in  contact  soft  and  slippery,  and  it  has  very 
considerable  haemostatic  power.  It  can  be  used  for  all  purposes  in 
obstetric  practice,  except  if,  in  cases  of  endometritis,  we  want  to 
judge  of  the  condition  of  the  uterus  by  means  of  the  character  of 
the  fluid  returning  from  its  interior.  Under  such  circumstances  a 
clear  fluid  is  needed,  such  as  plain  water,  normal  salt  solution,  solu- 
tion of  carbolic  acid  (from  one  to  two  per  cent.),  or  boric  acid  (the 
saturated  solution, — that  is,  four  per  cent.).  Otherwise  it  is  of  little 
importance  that  creolin  forms  an  opaque  mixture  \nth  water,  since 
nearly  all  obstetric  instruments  are  of  large  size. 

Lysol  is  a  brown  fluid  which  forms  a  slightly  greenish,  soapy  mix- 
ture with  water,  but  mixed  with  blood  it  becomes  almost  black.  It  is 
serviceable  in  obstetric  practice,  in  a  strength  of  one-half  to  one  per 
cent. 

It  is  very  desirable  to  have  one  of  these  two  drugs,  lysol  or  cre- 
olin, on  hand  in  private  practice,  as  they  are  slippery  enough  to  allow 
the  hand  and  arm  to  be  introduced  into  the  uterus  without  having 
recourse  to  the  doubtful  lubricants  sold  as  aseptic  and  antiseptic. 

In  pelvic  abscess  the  writer  uses  tincture  of  iodine,  from  one  to 
three  per  cent. 

Alcohol,  fifty  per  cent.,  is  also  much  used  and  praised  for  mtra- 
uterine  injection,  but  is  rather  expensive,  since  from  one  to  two 
quarts  are  used  for  one  injection. 

When  an  intra-uterine  injection  is  to  be  made  immediately  after 
delivery,  the  accoucheur  should  measure  the  distance  from  the 
vulva  to  the  fundus  by  holdmg  the  tube  outside  of  the  body.  Next 
he  should  mtroduce  his  left  index  and  middle  fmger  into  the  cer- 
vical canal  and  carry  the  tube  in  between  these  two  fmgers  with  the 
right  hand,  performing  a  circular  movement  corresponding  to  the 
physiological  anteflexion  of  the  uterus.  If  he  meets  with  any  resist- 
ance, he  must  beware  of  using  any  force,  by  which  the  uterine  wall 
is  easily  perforated.  He  must  change  the  direction  of  the  tube  until 
it  enters  easily,  and  he  should  not  inject  any  fluid  until  by  external 
palpation  he  has  felt  the  end  of  the  tube  resting  against  the  fundus 
of  the  uterus. 

For  intra-uterine  injections  the  can  should  not  be  held  higher  than 
a  foot  over  the  uterus,  so  as  to  avoid  the  too  forcible  rush  of  fluid 
against  the  openings  of  the  veins  of  the  placental  site.  At  the  end  of 
the  injection  the  fluid  should  be  sc|ueezed  out  from  the  uterus. 
Before  makmg  any  mjection,  vaginal  or  uterine,  the  air  should  be 
expelled  from  the  apparatus  by  holdmg  the  tube  upward  and  turning 
on  the  fluid. 


INTRAVENOUS   AND    SUBCUTANEOUS   INJECTIONS.  581 

Propkylactic  intra-uterine  injections  are,  in  the  author's  opinion, 
indicated  in  every  case  in  which  it  has  become  necessary  to  introduce 
fingers,  the  whole  hand,  or  instruments  into  the  uterine  cavity.  Since 
it  is  impossible  to  disinfect  the  vagina  and  the  hand  perfectly,  some 
protection  is  afforded  by  wasliing  out  with  an  antiseptic  fluid  that 
part  of  the  parturient  canal  that  has  been  invaded. 

The  second  indication  for  prophylactic  intra-uterine  injections 
is  the  birth  of  a  macerated  child  surrounded  by  decomposed  liquor 
amnii. 

We  have  seen  above  (p.  203)  that  I  use  a  prophylactic  vaginal  in- 
jection only  if  there  is  a  purulent  discharge  during  pregnancy. 

As  a  curative  measure  vaginal  and  intra-uterine  injections  are  used 
to  arrest  hemorrhage  (pp.  512,  513). 


CHAPTER    VI. 
INTRAVENOUS   AND    SUBCUTANEOUS   INJECTIONS. 

When  a  patient  has  lost  much  blood,  the  quantity  of  fluid  circu- 
lating through  her  heart  should  be  increased.  To  do  this  with  real 
blood  is  not  convenient.  Blood  of  animals  must  under  no  circum- 
stances be  used,  as  that  causes  a  dissolution  of  the  human  blood- 
corpuscles.  Human  blood  is  not  easily  obtained,  and  must  be 
defibrinated  by  beating  it  with  a  silver  fork  while  it  runs  out  of  the 
donor's  vein  and  strained  through  a  clean  cloth  of  tight  texture, 
preferably  white  satin.  AVhile  the  blood  is  passing  it  must  not  be 
stirred,  as  otherwise  fine  emboli  may  be  pressed  through  the  straining- 
cloth  and  cause  dangerous  collapse. 

It  was  therefore  a  great  improvement  when  it  was  discovered  that 
blood-corpuscles  are  not  needed  in  the  injected  fluid,  and  that  the 
serum  might  be  replaced  by  a  solution  of  sodium  chloride,  so-called 
normal  salt  solution  (6  :  1000,  or  practically  an  even  teaspoonful  to  a 
quart  of  sterilized  water). 

If  a  prompt  action  is  needed,  a  vein  should  be  laid  open  at  the 
patient's  elbow  and  a  quart  of  normal  salt  solution  at  a  temperature 
of  120°  F.  be  slowly  injected  in  the  direction  of  the  heart.  This  may 
be  done  with  my  transfusion  and  infusion  apparatus.  In  less  urgent 
cases  the  fluid  may  be  injected  anywhere  under  the  skin  where  there 
is  much  loose  connective  tissue,  especially  between  the  clavicle  and 
the  breast  (hyjwdermocli/sis). 

If  sterilized  water  is  not  obtainable,  the  injection  under  the  skin 
should  be  made  anyhow,  as  the  patient  is  in  danger  of  her  life,  but 
then  large  abscesses,  that  may  take  two  months  to  heal,  will  develop, 
and  be  followed  by  unsightly  scars.     In  such  a  case  less  conspicuous 


582  OBSTETRIC   OPERATIONS. 

places  should  be  chosen  for  the  insertion  of  the  needle.  While  the 
water  enters,  the  region  should  be  massaged,  so  as  to  press  the  fluid 
into  the  veins  and  gain  room  for  a  new  quantity  to  be  injected. 
Stimulants  for  heart  and  lung  should  be  injected  with  a  hypodermic 
syringe  under  the  skin,  especially  strychnine  (gr.  -^-^ — 2  milligranmies 
— until  gr.  y\ — 6  milligrammes — in  all  is  given),  tincture  of  digitalis 
(n\,x — 60  centigrammes — repeated  until  3ss — 2  grammes — is  given), 
and  nitroglycerin  (from  gr,  yio-  to  gr.  ^3 — from  |-  milligramme  to  2 
milligrammes).  Injection  of  3ss — 2  grammes — of  a  solution  of  1  part 
of  camphor  in  4  parts  of  sterilized  olive  oil  into  the  deltoid  or  vastus 
externus  is  efficacious  and  harmless. 

The    writer   has    constructed   an    apparatus  for  transfusion  and 
infusion^  (Fig.  421),  which  is  so  small  and  light  that  it  can  easily  be 

Fig.  421. 


Gamgues's  apparatus  for  transfusion  and  infusion.    A,  plunger;  B,  bulb;  C,  stopcock;  D,  needle; 
E,  flexible  probe-pointed  canula ;  F,  scissors ;  G,  thumb-forceps. 

carried  in  the  obstetric  bag.  It  is  essentially  a  diminutive  Davidson's 
syringe.  It  consists  of  two  rubber  tubes,  united  by  a  rubber  bulb 
with  two  metal  cup-valves  opening  in  the  same  du-ection.  At  one 
end  of  the  histrument  is  a  tin  plunger,  at  the  other  a  nickel-plated 
stopcock  and  silver  canula  or  needle.  The  canula  is  of  small  calibre, 
tapering,  probe-pointed,  and  flexible. 

The  whole  instrument  can  be  boiled.  Before  using  it  all  air 
should  be  carefully  driven  out  by  completed  compression  of  the  bulb 
while  the  plunger  and  the  tip  of  the  canula  are  immersed  in  the  fluid, 
which  is  kept  in  a  bottle  surrounded  by  hot  water  in  order  to  prevent 

^  Garrigues,  "Apparatus  for  Transfusion,"  Amer.  Jour.  Obst.,  vol.  xi.,  No.  4, 
October,  1878. 


ARTIFICIAL  DILATATION   OF   THE    CERVIX    DURING   LABOR.      583 

the  temperature  of  the  fluid  from  smkmg.  This  may  vary  from  110° 
to  120°  F.     From  a  pint  to  a  quart  may  be  injected. 

A  vein  is  exposed  at  the  elbow-bend  by  folding  the  skin  over  it  and 
incising  it.  If  no  vein  is  visible,  it  may  be  made  so  by  compression 
above  the  wound  as  for  phlebotomy.  In  order  not  to  lose  the  vein, 
if  by  chance  the  canula  should  slip  out  of  it,  it  is  advisable  to  pass  a 
probe  or  a  double  thread  under  it.  The  best  way  of  opening  the  vein 
is  to  seize  its  anterior  wah  with  a  fine  pair  of  forceps  or  a  tenaculum 
and  make  a  nick  in  it  with  a  pair  of  fine  scissors.  Thus  a  minute  flap 
is  formed,  under  which  the  point  of  the  canula  is  introduced  in  the 
direction  of  the  heart.  The  fluid  should  be  injected  very  slowly,  in 
order  to  avoid  dilatation  of  the  right  side  of  the  heart.  Three,  seconds 
should  be  the  very  shortest  time  left  between  two  compressions  of 
the  bulb.  The  bulb  holds  three  drachms,  but  by  moderate  pressure 
only  two  drachms  are  expelled  from  it.  If  a  resistance  is  felt,  the 
injection  should  be  interrupted  or  discontinued  altogether.  The  same 
rule  apphes  when  dyspnoea  or  other  untoward  symptoms  occur.  After 
the  operation  the  wound  is  dressed  as  after  phlebotomy. 

The  same  apparatus  may  be  used  for  hypodermoclysis,  only  that 
a  needle  then  is  used  instead  of  the  canula.  The  needle  may  also  be 
attached  to  a  fountain  syringe,  where  gravity  is  used  as  motor  power. 


CHAPTER    VII. 
ARTIFICIAL  DILATATION    OF   THE    CERVIX   DURING   LABOR. 

The  forceps  should  never  be  applied  before  the  os  is  perfectly- 
dilated,  and  the  same  rule  applies  to  version,  if  it  is  to  be  followed 
immediately  by  extraction.  Since,  on  the  other  hand,  the  life  of  the 
mother  and  that  of  the  child  may  depend  upon  a  speedy  deliver}^  the 
accoucheur  should  be  perfectly  familiar  with  all  means  by  which  the 
dilatation  of  the  cervix  may  be  induced,  increased,  or  completed. 

The  induction  of  premature  labor  has  been  discussed  in  Chapter 
IV.,  p.  572. 

During  labor  we  have  many  means  of  dilating  the  cervix.^  Cer- 
tain drugs  are  of  more  or  less  value  in  this  respect,  and  may  be  used 
when  there  is  no  immediate  danger,  or  may  be  combined  with  the 
mechanical  resources  presently  to  be  reviewed. 

From  olden  times  belladonna  has  been  used.  To  smear  the  cer- 
vix with  unguentum  belladonnse  must  be  looked  upon  as  obsolete,  on 
account  of  the  danger  of  infection,  but  in  the  refined  shape  of  atro- 

1  Garrigues,  "The  Dilalation  of  the  Cervix  Uteri  in  Obstetric  Practice," 
Med.  News,  September  21,  1901,  p.  447. 


584  OBSTETRIC    OPERATIONS. 

pine,  dissolved  in  sterilized  water,  it  may  be  injected  in  the  dose  of  4V 
grain  (IJ  milligrammes)  into  the  tissue  of  the  cervix.  The  cervical 
portion  may  be  painted  inside  and  outside  with  a  1 0  per  cent,  solution 
of  cocaine.  Chloral  hydrate  given  by  the  mouth  in  the  dose  of  gr.  xv 
(1  gramme),  repeated  every  twenty  minutes,  for  three  or  four  doses, 
has  an  excellent  effect.  Antipyrin,  gr,  x  (60  centigrammes)  every  half 
hour,  if  necessary  three  times,  has  undoubtedly  great  oxytocic  value, 
and  so  has  strychnine,  gr.  -gV  (2  milligrammes),  repeated  every  twenty 
minutes,  until  gr.  yV  (^  milligrammes)  has  been  given.  Quinine  in 
ten-grain  doses  has  also  been  praised  for  its  action  in  strengthening 
labor-pains  and  thereby  contributing  to  the  dilatation  of  the  cervix. 
Ipecacuanha,  gr.  ii  to  v  (12-30  centigrammes),  repeated  every  twenty 
to  thirty  minutes,  is  disagreeable  in  so  far  as  it  nauseates  the  patient, 
but  it  conquers  rigidity  of  the  cervix. 

Dr.  A.  Rose,  of  New  York,^  praises  a  vaginal  douche  of  carbonic 
acid.  The  gas  may  be  generated  by  mixing  a  solution  of  3vi  (24 
grammes)  of  bicarbonate  of  sodium  with  siv  (16  grammes)  of  tartaric 
acid,  in  large  crystals,  which  produce  a  slow  development  of  carbonic 
acid.  The  solution  is  kept  in  a  wide-mouthed  glass  bottle,  with  per- 
forated rubber  stopper,  through  which  goes  a  hard-rubber  tube.  To 
this  is  attached  a  soft-rubber  tube,  ending  in  a  vaginal  nozzle  of  hard 
rubber.  The  gas  is  said  to  anaesthetize  the  A^agina  and  cervix  and  to 
cause  dilatation  of  the  latter,  but  is  chiefly  efficacious  in  primiparae, 
much  less  in  pluriparse. 

Among  the  mechanical  means  available,  when  there  is  no  hurry, 
I  shall  first  mention  the  introduction  into  the  uterus  of  a  bougie, 
which,  in  the  author's  experience  in  confinements  at  term,  has  proved 
a  powerful  inciter  of  the  uterine  contractions  in  cases  of  absent  labor- 
pains. 

Tamponade  may  be  applied  to  the  vagina,  the  cervix,  or  the  inte- 
rior of  the  body  of  the  uterus.  A  good  way  of  obtaining  dilatation 
of  the  cervix  is  to  insert  a  strip  of  iodoform  gauze  into  the  cervical 
canal  as  far  as  it  will  go  and  pack  the  vagina  with  the  same  material 
or  absorbent  cotton  wrung  out  of  creolin  (one  per  cent.).  The  next 
day  the  packing  is  removed,  when  the  internal  os  will  probably  be 
found  so  dilated  that  new  gauze  may  be  placed  beyond  it,  inside  of 
the  lower  uterine  segment,  where  it  works  as  an  irritant,  calling  forth 
uterine  contractions. 

If  the  situation  is  such  that  we  want  the  os  dilated  as  rapidly  as 
possible,  for  instance,  in  a  case  of  uterine  hemorrhage,  we  have  dif- 
ferent resources,  namely,  manual  dilatation,  dilatable  bags  filled  with 
a  fluid,  expanding  metal  dilators,  and  deep  cervical  incisions. 

Manual  Dilatation. — Those  who  have  not  tried  it  have  no  idea  how 
1  Rose,  Deutsche  Praxis,  No.  11,  1901. 


ARTIFICLVL   DILATATION    OF   THE    CERVIX    DURING   LAROR.      585 

often  the  cervix  towards  the  end  of  pregnancy  is  so  dilatable  that  in 
from  fifteen  to  twenty  minutes  it  may  be  fully  dilated.  Manual  dila- 
tation, as  introduced  by  Dr.  Philander  Harris,  of  Paterson,  N.  J., 
differs  much  from  what  was  known  a  few  years  ago  and  is  still  taught 
in  Europe.  According  to  the  old  method  we  introduce  first  one  fmger, 
then  two,  three,  four,  the   whole  hand  formed  into  a  cone,  always 


Fig.  422. 


^iwTars 


Harris's  method  of  manual  dilatation  of  the  cervix. 

C 


■  Harris's  method  of  rapid  dilatation  of  the  cervix,  last  stage. 

pressing  upward,  using  the  extensor  muscles  of  the  hand  and  arm, 
Avith  counter-pressure  on  the  fundus.  In  Harris's  method  ^  the  thumb 
and  fingers  are  crossed,  and  the  cervix  is  opened  by  lateral  pressure 
exercised  by  the  flexor  muscles  of  the  hand  and  forearm. 

This  method  is  applicable  in  any  case  of  delivery  towards  the  end 
>  P.  A.  Harris,  Amer.  Jour.  Obst.,  1894,  vol.  xxix.,  No.  1. 


586  OBSTETRIC    OPERATIONS. 

of  pregnancy,  say  from  the  end  of  the  seventh  month,  provided  the 
index-fmger  can  be  inserted  through  the  cervical  canal  to  its  full 
extent.  First  the  index-fmger  is  introduced  by  simple  pressure  against 
the  OS.  Next  the  fmger  is  drawn  back  to  its  tip,  and  the  tip  of  the 
thumb  made  to  enter  together  with  the  former.  As  soon  as  the 
thumb  and  first  fmger  have  passed  the  os,  they  are  crossed  (Fig. 
422,  A),  and  pressure  is  exerted  on  the  os.  Gradually  the  second, 
third,  and  fourth  fingers  are  added  and  bent  like  the  index-finger  (Fig. 
422,  £).  Finally,  the  thumb  is  stretched  and  the  os  made  to  surround 
its  first  phalanx  and  the  second  phalanx  of  the  somewhat  separated, 
bent  fingers  (Fig.  422,  C).  During  all  of  these  manipulations  the  hand 
reposes  in  the  vagina.  In  from  sixteen  to  twenty-two  minutes  full 
dilatation  is  obtained,  allowing  podalic  version  and  extraction. 

Another  method  of  manual  dilatation  that  is  used  a  great  deal  in 
this  country  is  that  invented  by  the  French  obstetrician  Bonnaire  for 
the  treatment  of  placenta  prsevia.  While  Harris  uses  only  one  hand, 
Bonnaire  employs  both.  The  patient  is  angesthetized  and  placed  on  a 
table  in  the  dorsal  position,  with  her  legs  strongly  flexed.  If  she  is  not 
in  labor  the  right  index-fmger  is  bored  through  the  cervix  as  in  Har- 
ris's method.  When  it  has  passed  the  internal  os,  it  is  used  to  massage 
the  surrounding  tissue  in  an  excentric  direction.  When  the  canal  is 
sufficiently  dilated  the  left  index  is  inserted  parallel  to  the  other  and 
back  against  back.  If  the  cervix  is  short,  or,  still  better,  if  it  is 
partially  dilated,  it  is  easy  to  introduce  the  two  fingers,  but  if  it  is 
long  and  situated  high  up  in  the  pelvis,  it  is  necessary  to  let  an  assist- 
ant press  the  uterus  down  through  the  abdominal  wall.  The  opera- 
tor introduces  his  two  index-fingers  as  deep  as  he  can  and  separates 
the  cervical  walls  transversely,  and,  at  the  same  time,  pulls  them  down- 
ward. Sliding  the  fingers  up  alternately  he  succeeds  finally  in  pass- 
ing the  internal  os.  Next,  those  two  fingers  are  bent  outward,  using 
the  metacarpophalangeal  joint  as  a  fulcrum.  By  moving  them  to 
different  points  of  the  circumference  and  massaging  the  cervix,  this 
is  gradually  softened  and  •  made  to  yield.  No  sudden  or  great  force 
should  be  used;  the  flexors  of  the  hands  only  should  be  contracted; 
the  object  is  rather  to  tire  out  the  cervical  sphincter  than  to  over- 
come it  by  main  force.  If  the  accoucheur  hears  a  crackling  sound  it 
means  that  some  fibres  of  the  cervical  muscle  have  been  ruptured, 
when  it  is  advisable  to  moderate  the  pressure  and  change  the  direc- 
tion. When  the  cervix  is  wide  enough,  the  right  middle  finger  is 
inserted  with  the  two  index-fingers,  next  the  left  middle  finger,  then 
the  third  finger  of  the  right  hand,  and  finally  that  of  the  left.  By 
means  of  these  six  fingers  the  cervix  may  be  fully  dilated  till  the 
edges- simultaneously  touch  the  two  sides  of  the  pelvis. 

Either  of  these  methods  of  manual  dilatation  is  preferable  to  the 


ARTIFICIAL  DILATATION    OF   THE   CERVIX    DURING   LABOR.      587 

pressure  with  the  cone-shaped  hand,  which  is  apt  to  cause  great  tears 
in  the  parametria  and  the  broad  ligaments,  and  does  not  furnisli  the 
same  degree  of  dilatation.  They  are  also  preferable  to  any  hard 
dilating  instrument.  Having  the  fingers  directly  in  contact  with  the 
tissues  we  press  on,  we  can  better  judge  of  their  condition  and  handle 
them  with  greater  gentleness. 

Bags  capable  of  being  filled  with  fluid  are  also  of  the  greatest  value. 
We  have  two  classes  of  apparatus  of  this  kind, — the  elastic  and  the 
unyielding.  The  elastic  bag  was  first  used  in  the  vagina  as  Braun's 
colpeurynter^  an  egg-shaped  rubber  bag  with  a  tube  and  stopcock.  It 
may  be  filled  with  ice-water  and  thus  add  the  element  of  refrigeration 
to  that  of  pressure.  As  a  tampon  it  is  inferior  to  other  devices,  but  as 
an  exciter  of  labor-pains  by  reflex  action  it  has  considerable  power. 

Tarnier  invented  a  little  bag  with  tube  which  placed  above  the 
internal  os  irritated  the  lower  uterine  segment  by  direct  contact. 

Barnes's  dilators  (Fig.  415,  p.  573)  add  to  this  irritation  direct 
expansion  of  the  cervix.  They  are  most  excellent  as  far  as  they  go. 
I  cannot  even  subscribe  to  the  common  complaint  that  has  been 
uttered  against  them  that,  on  account  of  their  elasticity,  they  become 
more  dilated  at  the  two  ends  and  less  in  the  middle,  where  dilatation 
is  most  needed.  I  have  used  them  for  many  years  and  would  not 
think  of  going  to  a  confinement  without  them,  and  I  have  certainly 
found  that  they  dilate  until  the  fiddle-shape  is  changed  into  a  cylinder, 
when  they  are  pushed  out.  But  even  the  largest  dilatation  obtained 
is  only  7  inches  (18  centimetres)  in  circumference,  or  about  2|-  inches 
(6  centimetres)  in  diameter. 

It  was  therefore  a  decided  improvement  when  Champetier  de 
Ribes  invented  his  pear-shaped,  unyielding  bag  (Fig.  418,  p.  575), 
which  when  fully  dilated  measures  nearly  4  inches  (10  centimetres) 
across  the  base.  A  rope  may  be  attached  to  the  tube  of  the  bag  and 
led  over  a  pulley.  To  the  other  end  of  the  rope  may  be  fastened 
weights. 

In  spite  of  indisputable  merits,  this  dilator  is  not  without  draw- 
backs. It  is  apt  to  provoke  too  rapid  and  violent  contractions,  it 
favors  the  prolapse  of  the  umbilical  cord,  and  it  may  push  the  pre- 
senting part  away  from  the  brim  of  the  pelvis. 

This  dilator  is  particularly  praised  for  the  induction  of  premature 
labor,  and  in  placenta  prfevia,  the  treatment  of  which  formidable  com- 
pHcation  it  has  changed.  Instead  of  turning  by  Braxton  Hicks's 
method  (see  below)  and  using  the  breech  and  thigh  of  the  foetus  as  a 
tampon,  the  large  unyielding  bag,  introduced  through  the  torn  mem- 
branes or  perforated  placenta,  arrests  hemorrliage  by  direct  pressure 
of  the  bleeding  surface  of  the  uterus  and  allows  the  use  of  the  for- 
ceps, which  has  diminished  the  fetal  mortality  enormously. 


588 


OBSTETRIC    OPERATIONS. 


Fig.  423. 


Hard  Dilators. — The  hard  dilators  may  also  be  divided  into  two 
classes, — those  by  which  pressure  is  exercised  all  over  the  circum- 
ference, but  chiefly  in  the  direction  of  the  longitudinal  axis  of  the  cer- 
vical canal,  and  those  which  only  exert  lateral  pressure,  but  then 
necessarily  only  on  comparatively  small  surfaces  at  a  time.  The  first 
class  of  instruments  are  cone-shaped  or  olive-shaped.  There  are  a 
set  of  coniform  dilators  devised  by  Hanks  (Fig.  402,  p.  566)  and 
Garrigues's  set  of  small  and  Hanks's  of  large  olive-shaped  dilators 
(Fig.  404,  p.  567).  These  instruments  are  all  useful  in  abortion 
cases  and  the  induction  of  premature  labor.  In  delivery  at  or  near 
term  the  expanding  dilators  are  preferable.  Arthur  Mliller's  (Fig. 
423)  has  two  branches.  Bossi's  has  three.  In  severe  labor  cases 
the  cervix  can  be  opened  with  these  expanding  dilators  in  from  fifteen 
to  twenty  minutes,  and  in  abortion  cases  sufficient  dilatation  is  ob- 
tained in  five  or  six  minutes. 

To  instruments  applies  the  same  that  we  said  above  about 
manual  dilatation.  Lateral  pressure,  even  if  exercised  only  on  a  few 
points  of  the  circumference  at  a  time,  is  to  be  preferred  to  the  push- 
ing upward  of  large  bodies  in  the  direction  of  the  cervical  canal. 
By  moving  the  rods  of  the  expanding  dilators 
around  to  different  points  of  the  cervix,  we  obtain 
an  even  dilatation  and  are  less  apt  to  tear  the 
cervix  and  the  parametrium. 

A  weak  electric  battery  current,  the  positive 
pole  at  the  fundus,  the  negative  on  the  sides  of 
the  cervix,  in  the  cervical  canal  or  against  the 
vault  of  the  vagina,  may  be  used,  but  demands 
caution,  in  order  not  to  harm  the  foetus. 

Finally,  we  have  the  deep  cervical  incisions. 
To  make  several  small  incisions  in  the  circum- 
ference of  the  OS  is  an  old  method  that  often  has 
proved  useful  in  overcoming  rigidity  of  the  cervix, 
but  sometimes  these  incisions  tear  out,  and  it  can- 
not be  calculated  how  far  the  laceration  will  ex- 
tend. Of  late  years  a  regular  operation  has  been 
substituted  by  Diihrssen,  of  Berlin.  He  makes 
two  lateral  incisions,  and  adds  sometimes  a  pos- 
terior and  an  anterior  in  the  median  line.  These 
incisions  divide  the  whole  cervical  portion  out  to 
the  vaginal  vault.  In  order  to  obtain  the  full 
length  of  these  incisions,  it  is  necessary  to  seize 
the  cervix  with  two  pairs  of  bullet-forceps  and  cut  between  them. 
The  advantage  of  this  method  is  that  it  affords  space  immediately,  but 
it  is  indicated  only  when  the  cervix  is  obliterated  and  the  os  not 


Cervical  dilator  of  Arthur 
Miiller,  of  Munich. 


EXPRESSION    OF   THE   F(ETUS.  589 

sufficiently  dilated.  Before  delivery  these  incisions  do  not  bleed 
much,  because  the  uterus  is  compressed  between  the  head  of  the 
fcetus  and  the  brim  of  the  pelvis.  But  after  the  expulsion  or  ex- 
traction of  the  child,  when  the  pressure  ceases,  there  is  apt  to  come 
hemorrhage.  Even  such  deep  incisions  may  tear  farther  and  give  rise 
to  an  irregular  wound.  The  danger  of  infection  is  also  increased. 
The  incisions  do  not  always  heal  together,  in  which  case  there  would 
remain  a  laceration  of  the  cervix.  If  these  incisions  are  made  at 
all,  they  ought  therefore  to  be  united  with  sutures  immediately  after 
deliver}^,  by  which  hemorrhage  is  arrested  and  linear  union  without 
cicatricial  tissue  is  obtained.  But  to  put  in  stitches  with  the  defective 
assistance  and  arrangements  usually  found  in  private  practice  is  no 
easy  matter.  In  order  to  make  the  wounds  accessible,  an  assistant 
should  press  the  uterus  well  down  into  the  pelvis,  when  the  edges 
of  the  wounds  may  be  seized  with  forceps  and  stitched  together.  It 
must  be  admitted  that  by  this  method  a  child's  life  may  be  saved  that 
otherwise  would  be  lost ;  but  it  exposes  the  mother  to  immediate 
danger  and  remote  suffering.  It  can  therefore  hardly  be  recommended 
when  compared  with  bloodless  dilatation,  manual  or  instrumental. 

Indications  for  Artificial  Dilatation  of  the  Cervix  during  Labor. — 
This  operation  is  indicated  when  the  labor-pains  are  defective  in 
strength  and  frequency ;  in  eclampsia  ;  in  ante-partum  hemorrhage ; 
in  any  other  condition  that  jeopardizes  the  mother's  life,  and  in  which 
amelioration  may  be  expected  by  the  speedy  termination  of  labor; 
and  finally  when  the  life  of  the  foetus  is  endangered,  for  instance  by 
prolapse  of  the  cord  (p.  414). 


CHAPTER    VIII. 
EXPRESSION    OF   THE   FCETUS. 

Pressure  may  sometimes  be  used  to  great  advantage  for  the  pur- 
pose of  delivering  a  woman.  We  have  mentioned  how  the  head  may 
be  enucleated  by  pressure  through  the  rectovaginal  septum  (p.  193). 
We  have  recommended  pressure  from  above  on  the  after-coming  head 
in  breech  presentations,  either  alone  or  combined  with  traction  on 
the  shoulders  of  the  foetus  (p.  384),  by  which  the  chin  is  pressed 
against  the  fetal  chest,  and  the  head  made  to  pass  the  pelvis  with  its 
small  diameters. 

Pressure  through  the  abdominal  wall  may  also  be  used  when 
the  head  presents.  If  the  head  does  not  engage  itself  in  the  brim,  the 
engagement  may  be  favored  by  direct  pressure  on  the  head  above  the 
symphysis  pubis.  In  cases  of  inertia  uteri  we  have  recommended 
(p.  358)  to  rub  the  fundus  and  to  press  on  it. 


590  OBSTETRIC   OPERATIONS. 

Pressure  should  be  resorted  to  only  in  the  second  stage.  If  excep- 
tionally there  are  intestinal  knuckles  lying  between  the  abdominal 
wall  and  the  uterus,  they  should  first  be  pushed  aside.  Next  the 
accoucheur  places  his  thumbs  in  front  of  the  fundus  and  the  eight 
fingers  behind  it  and  exercises  pressure  m  the'  direction  of  the  pel- 
vic brim,  beginning  very  gently  and  gradually  increasing  in  strength, 
thus  imitating  natural  labor-pains.  The  pressure  should  be  inter- 
mittent and  chiefly  be  used  as  an  adjuvant  to  already  existing  con- 
traction. 

The  method  is  of  special  value  in  those  cases  in  which  the  con- 
traction ring  has  receded  high  up.  The  foetus  is  pushed  into  the  cer- 
vix and  vagina,  and  the  uterus  has  no  longer  any  power  over  it 
(p.  172).  Now  the  abdominal  pressure  should  take  the  place  of  the 
uterine  contractions,  but  the  woman  may  be  exhausted  or  shun  the 
pain  produced  by  contraction  of  the  abdominal  muscles.  Then  the 
pressure  by  the  accoucheur  may  replace  it.  But  since  this  also  causes 
pain,  it  may  be  well  to  give  a  little  chloroform. 

If  after  the  birth  of  the  head  the  shoulders  do  not  follow  easily, 
pressure  on  the  fundus  may  be  all  that  is  recjuired  for  a  speedy 
delivery. 

The  method  may  be  particularly  indicated  if  there  is  no  forceps 
at  hand  or  if  the  patient  objects  much  to  any  use  of  instruments. 


CHAPTER    IX. 
PREPARATION   FOR    OPERATIONS. 

The  more  common  operations,  such  as  forceps  extraction,  ver- 
sion, and  perineorrhaphy,  may  be  performed  without  removing  the 
patient  from  her  bed,  but  she  should  be  placed  across  the  bed  with  a 
pillow  under  her  head  and  shoulders,  the  buttocks  drawn  Avell  over 
the  edge  of  the  bed,  and  each  leg  bent  at  the  knee  and  placed  per- 
pendicularly on  a  chair,  while  the  operator  stands,  sits,  or  kneels 
between  the  two  chairs.  Each  knee  is  to  be  held  by  an  assistant,  but 
they  need  not  be  skilled ;  nor  is  it  necessary  that  they  see  what  the 
operator  is  doing,  which  is  so  much  more  valuable  since  the  unusual 
sight  is  apt  to  produce  faintness  and  incapacity  for  further  assistance. 

For  the  greater  operations — symphyseotomy,  Csesarean  section, 
and  embryotomy — the  patient  should  be  placed  on  a  table,  as  for 
any  major  operation.  A  common  kitchen  table,  four  feet  long  and  two 
feet  wide,  is  very  convenient.  It  should  be  covered  with  a  folded 
blanket  or  quilt,  a  muslin  sheet,  and  a  rubber  shee-t  or  oil-cloth.  The 
last-named  should  be  pinned  together  so  as  to  form  a  funnel  leading 


PREPARATION    FOR    OPERATIONS.  591 

from  the  lower  end  of  the  table  into  a  pail.  Instead  of  this  arrange- 
ment an  inflatable  rubber  cushion  witii  apron  may  be  used  (Fig.  219, 
p.  182).  A  pillow  is  placed  at  the  head  of  the  table,  and  this  end  is 
slightly  raised  so  that  fluids  gravitate  into  the  pail. 

In  hospitals  tables  are  used  that  can  be  thoroughly  disinfected, 
and  that  have  stirrups  for  raising  the  feet  and  arrangements  for  ele- 
vating the  pelvis. 

In  private  practice  the  elevated-pelvis  position  may  be  improvised 
by  means  of  a  chair  or  an  ironing-board  (Fig.  330,  p.  416). 

Position. — The  best  positions  for  the  patient  to  occupy  during  the 
different  stages  of  normal  labor  have  been  discussed  on  p.  191.  For 
operations,  as  a  rule,  the  dorsal  position,  with  somewhat  raised  head 
and  shoulders,  bent  knees,  and  spread  heels,  is  the  most  convenient. 
Exceptionally,  especially  in  performing  version,  the  lateral  position,  on 
one  or  the  other  side,  gives  easier  access  to  the  uterine  cavity.  The 
elevated-pelvis  jiosition  is  used  to  advantage  in  the  reposition  of  the 
prolapsed  cord. 

A  sitting  posture  is  used  less  nowadays  than  formerly,  when  a  de- 
livery-chair formed  part  of  a  well-appointed  trousseau.  The  time  of 
this  piece  of  furniture,  that  sometimes  descended  from  one  generation 
to  the  other,  and  was  one  of  the  requisites  of  a  midwife,  is^one,  and 
the  position  is  rarely  needed.  But  as  a  matter  of  fact  it  is  probably 
the  most  common  position  instinctively  taken  by  the  unassisted 
woman  in  labor.  To  crouch  down  on  her  feet  is,  however,  very 
fatiguing.  The  comfort  of  support  may  easily  be  supplied  by  placing 
two  chairs  together  so  that  they  touch  each  other  with  the  backs 
and  leaving  the  seats  separated  at  an  angle  of  about  forty-five  degrees. 
The  patient  may  sit  with  one  buttock  on  each  chair,  which  leaves  free 
access  to  the  genitals.  An  assistant  should  support  her  from  behind, 
and  the  accoucheur  sits  on  a  low  chair  or  footstool  in  front  of  the 
patient  ready  to  receive  the  child  and  prevent  it  from  falling  on  the 
floor. 

Hanging  Posture. — It  has  been  known  for  centuries  that  in  diffi- 
cult deliveries  some  aid  might  be  obtained  by  laying  the  patient  on  a 
high  couch  and  letting  her  legs  hang  down,  just  touching  the  floor. 
This  position  has  been  scientifically  investigated  of  late  years  and  is 
now  known  as  the  hanging  posture  of  Walcher  (Fig.  424).  In  this 
posture  an  increase  in  the  true  conjugate  of  from  five  to  thirteen  milli- 
metres (;^-|  inch)  is  obtained.  This  is  due  to  a  rotation  taking  place 
in  the  iliosacral  articulation,  the  innominale  bone  being  moved  for- 
ward and  downward  by  the  weight  of  the  lower  half  of  the  body  or 
by  traction  on  the  foetus. 

This  position  is,  therefore,  of  value  in  minor  degrees  of  mechanical 
disproportion  between  the  brim  of  the  pelvis  and  the  presenting  part. 


592 


OBSTETRIC    OPERATIONS. 


It  may  be  utilized  in  extraction,  be  it  by  hand  or  forceps,  to  pull  the 
head  into  the  pelvic  cavity,  and  may  to  advantage  be  combined  with 
pressure  from  above. 

Ancesthesia. — For  all  operations  the  patient  should,  as  a  rule,  be 
anaesthetized.  It  is  not  only  humane  to  do  so  in  order  to  avoid  pain, 
but  most  operations  are  performed  more  easily  when  muscular  con- 
traction on  the  patient's  part  is  eliminated.  This  applies  particularly 
to  examination  with  the  whole  hand,  correction  of  faulty  positions, 

Fig.  424. 


Hanging  posture  of  Walcher. 

and  extraction.  But  the  patient  may  be  so  weak  from  loss  of  blood 
or  nervous  exhaustion  that  it  would  add  to  the  danger  to  anaesthetize 
her,  and  then  it  should  not  be  done. 

For  common  operations,  chloroform,  which  ought  always  to  be 
present,  is  quite  available.  For  longer  operations,  such  as  symphyse- 
otomy, Caesarean  section,  and  embryotomy,  I  prefer  ether  as  the  safer 
anaesthetic. 

What  to  do  in  cases  of  eclampsia  with  a  urine  loaded  with  albumin 
is  hard  to  say,  the  advice  of  the  experimenters  diverging  widely  on 
this  important  point.  Schleich^  contends  that  on  account  of  its  high 
boiling-point — 149°  F. — chloroform  can  be  eliminated  only  through 

^  Schleich,  Schmerzlose  Operationen,  third  ed.,  Berlin,  1898,  p.  60. 


FORCEPS   DELIVERY.  593 

the  kidneys,  and  not  through  the  lungs,  as  is  ether.  According  to  him, 
chloroform  is,  therefore,  more  dangerous  than  ether  when  the  patient 
suffers  from  nephritis.  On  the  other  hand,  Drs.  W.  H.  Thomson  and 
R.  C.  Kemp,'  basing  their  views  on  experiments  on  dogs  and  rabbits 
with  the  oncometer,  an  instrument  which  shows  the  circulation  in 
the  kidney  as  compared  with  that  in  the  general  system,  declare  that 
chloroform  has  no  effect  on  that  organ,  while,  according  to  them, 
ether  is  contraindicated  in  kidney  disease,  especially  albuminuria  with 
tendency  to  pulmonary  oedema,  which  is  the  condition  in  eclampsia. 
So  far  I  have  always  avoided  ether  in  kidney  complaint. 

Chloroform  depresses  the  heart,  which  ether  strengthens,  but  in 
pregnancy  and  labor  we  have  a  strong  heart-action  which  counter- 
balances the  depressing  influence  of  the  drug.  Ether  is  more  dan- 
gerous than  chloroform  when  the  lungs,  the  larynx,  or  the  trachea  is 
affected,  and  in  patients  suffering  from  congestion  of  the  brain.  If 
heart  trouble  is  combined  with  lung  disease,  ether  is  more  contra- 
indicated  than  chloroform.  As  stated  above  (p.  206),  I  do  not  think 
the  subarachnoid  injection  of  cocaine,  on  account  of  the  short  dura- 
tion of  the  anaesthesia  in  some  cases,  apart  from  the  unreliability  and 
the  danger  inherent  in  the  method,  recommends  itself  in  such  work. 

If  there  is  no  skilled  assistant  present,  the  doctor  must  himself 
anaesthetize  the  patient  and  place  her  in  the  proper  position,  and 
thereafter  direct  the  husband  or  nurse  to  continue  the  anaesthesia 
under  his  direction.  For  the  greater  operations  proper  skilled  assist- 
ance is  imperative.  If  it  cannot  be  obtained,  the  patient  should  be 
removed  to  a  hospital  where  it  is  found. 

The  bladder  should  always  be  emptied  with  a  catheter  immedi- 
ately before  operations,  and  the  rectum  with  an  enema,  if  it  has 
not  recently  been  done. 

Jjife  of  the  Foetus. — Before  deciding  on  any  obstetrical  operation 
the  accoucheur  should  ascertain  by  means  of  the  stethoscope  or  pal- 
pation whether  the  foetus  is  dead  or  alive,  since  the  choice  of  the 
proper  operation  in  most  cases  varies  materially  with  its  life  or  death. 
When  the  foetus  is  dead,  everything  ought  to  be  done  to  facilitate 
delivery  for  the  mother.  While  it  is  alive  it  is  entitled  to  our  full 
consideration.  Nothing  is  more  common,  when  an  obstetrical  opera- 
tion is  proposed,  than  for  the  husband  to  say,  "Save  my  wife;  I 
do  not  care  for  the  child.''  The  accoucheur's  aim  should,  however, 
be  to  save  both,  if  it  is  feasible.  Only  when  the  interest  of  the 
mother  and  that  of  the  foetus  become  directly  opposed  to  each  other, 
that  of  the  mother  must  outweigh  the  other.  The  mother  is  an 
already  existing  human  being,  her  husband's  companion,  perhaps 
mother  of  other  children,  or  dear  to  other  human  beings,  while  the 

1  Thomson  and  Kemp,  Medical  Record,  Sept.  3,  1898. 
38 


594  OBSTETRIC    OPERATIONS. 

foetus  is  only  a  possibility,  that  may  die  before  it  is  born,  or  be  a 
cripple  or  an  idiot,  who  will  cause  its  parents  more  sorrow  than  joy, 
and  whose  life  will  be  of  little  value  to  itself  and  the  community. 
(Compare  Artificial  Abortion,  p.  269.) 

Asepsis  and  Antisepsis. — Since  it  is  never  known  beforehand  what 
complications  may  arise  in  a  confinement  case,  and  the  result  of  the 
operations,  inclusive  of  the  patient's  life,  largely  depends  on  the  avoid- 
ance of  infection,  it  is  of  paramount  importance  to  use  all  the  aseptic 
and  antiseptic  precautions  recommended  in  speaking  of  the  manage- 
ment of  normal  labor  (pp.  185,  188,  190).  The  author  has  there 
expressed  his  views  in  regard  to  the  question  of  disinfection  and 
sterilization.  In  lying-in  hospitals  an  obstetric  operation  should,  of 
course,  be  performed  with  the  same  minute  care  in  regard  to  avoiding 
sepsis  as  any  other  surgical  operation.  In  private  practice  we  must, 
as  a  rule,  be  satisfied  with  the  disinfection  of  the  hands  and  patient, 
as  described.  Instruments  and  rubber  articles  can  easily  be  boiled, 
and  by  adding  common  washing-soda  (a  tablespoonful  to  each  quart 
of  water),  which  is  found  in  most  houses,  perfect  asepsis  is  obtained 
in  two  minutes.  Cold  sterilized  water  is  very  desirable,  both  for  cool- 
ing the  boiled  instruments  and  for  mixture  with  hot  water  in  order  to 
obtain  a  proper  fluid  for  injection  into  the  vagina,  the  uterus,  or  under 
the  skin.  It  is  therefore  well,  in  the  beginning  of  labor,  to  order  some 
suitable  vessels  fihed  with  water,  boil  it,  and  leave  it  covered  until 
needed  (p.  577). 

Consultation. — Before  operating,  it  is  necessary  to  notify  the  hus- 
band or  other  friends  in  a  general  way  that  some  operation  is  needed 
to  deliver  the  woman.  Often  it  is  wise  to  ask  for  a  consultation  with 
a  specialist  or  another  physician.  Even  if  the  accoucheur  is  capable 
of  doing  the  work  himself,  he  may  need  skilled  assistance. 


CHAPTER    X. 
FORCEPS   DELIVERY. 


The  Construction  of  the  Forceps. — Before  entering  on  the  question 
of  forceps  delivery,  one  must  make  it  clear  what  is  meant  by  an 
obstetric  forceps.  There  are  many  kinds  of  forceps,  long  and  short, 
straight  and  curved,  symmetric  and  asymmetric ;  some  destined  to  he 
in  the  sides  of  the  pelvis,  others  in  the  anteroposterior  diameter,  etc. 
The  instruments  differ  so  much  in  size  and  shape  that  one  can  be 
used  for  purposes  for  which  another  is  inadequate  or  useless.  There 
are  hundreds  of  different  forceps,  and  new  models  are  being  offered 
all  the  time.     The  literature  on  this  subject  fills  volumes.     In  a  text- 


FORCEPS   DELIVERY. 


595 


book  like  this  it  would  be  out  of  place  to  enter  into  the  details  of  the 
history  of  this  instrument  and  describe  its  numerous  varieties.     We 


Fig.  425. 


W' 


A.  R.  Simpson's  axis-traction  forceps. 

admit  that  it  may  be  convenient  in  a  lying-in  hospital  to  have  special 
kinds  of  forceps  for  different  cases,  but  the  general  practitioner  will 
hardly  buy  more  than  one  forceps,  and  it  becomes  somewhat  a  question 
of  expediency  which  we  shall  recommend  him  to  buy.     I  will  state 

Fig.  426. 


Handle  of  the  same. 


right  here  that  since  1880  I  have  exclusively  used  Professor  Alexander 
Russell  Simpson's  axis-traction  forceps  (Figs.  425,  426),  which  can 


596 


OBSTETRIC    OPERATIONS. 


as  well  be  used  for  the  simplest  and  easiest  deliveries  as  for  the  most 
difficult.  Accident  may  have  had  some  influence  on  my  choice.  In  a 
case  of  contracted  pelvis  I  tried  both  Simpson's  and  Tarnier's  forceps. 
While  I  could  not  apply  the  latter,  the  former  gave  entire  satisfaction. 
I  therefore  introduced  it  in  my  service  at  the  New  York  Maternity 
Hospital,  and  placed  it  in  my  satchel  instead  of  the  one  without  traction 
rods  which  I  had  been  accustomed  to  use. 

The  obstetrical  forceps  was  invented  by  a  member  of  the  Cham- 
berlen  family,  and  almost  certainly  by  Peter  Chamberlen,  senior,  born 
in  Paris,  whose  parents  emigrated  to  England  in  1569,  where  they 
changed  their  name  from  Chambellan  to  Chamberlen.  Peter  Cham- 
berlen the  elder,  his  brother  Peter  Chamberlen  the*  younger,  and  the 
son  of  the  latter,  Dr.  Peter  Chamberlen,  all  used  the  instrument,  but 
kept  its  construction  secret  for  mercenary  reasons.  The  original  instru- 
ments belonging  to  Dr.  Peter  Chamberlen  have  been  found  and  are 
kept  in  the  Medical  and  Surgical  Society  of  London.  They  have  a 
cephalic  curvature,  crossed,  separable  branches,  but  no  pelvic  curva- 
ture (Fig.  427).     This  short  straight  forceps  was  further  developed  by 

Fig.  427. 


Chamberlen's  forceps. 


Levret,  of  Paris  (1747),  who  later  added  the  pelvic  curvature  (Fig,  428) 
and  made  the  instrument  so  long  that  it  could  be  used  at  the  superior 
strait,  and  by  Smellie,  in  England  (1751),  who  had  a  short,  straight, 
and  a  long,  curved  forceps,  and  invented  the  lock  used  ever  since 
on  English  forceps.  Since  then  numerous  prominent  professors  of 
obstetrics  and  many  obscure  physicians  have  remodelled  the  forceps. 

The  forceps  is  an  instrument  chiefly  destined  for  delivering  the 
head  and  occasionally  also  applied  to  the  breech. 

Most  modern  forceps  are  made  of  metal  alone,  and  if  hard  rubber 
is  used  on  the  handles,  on  account  of  its  low  specific  weight,  it  is 
vulcanized  on  the  metal  in  such  a  way  as  to  avoid  crevices  in  which 
dirt  may  lodge.  For  the  same  reason  all  ornamental  furrows  are 
discarded. 

The  forceps  consists  of  two  branches^  or  arms^  crossing  each  other 
at  the  loch.  Each  branch  is  composed  of  three  parts,  the  handle.,  the 
shank.,  and  the  blade.     The  handles  are  more  or  less  voluminous  and 


FORCEPS    DELIVERY. 


597 


have  on  most  forceps  wings  at  the  proximal  or  distal  end  and  along 
their  sides  indentations  for  the  fingers.  At  the  upper  end  of  the 
handle  is  the  so-called  lock.     In  the  French  forceps  this  is  a  real  lock 

Fig.  428. 


Levret's  forceps. 


closed  with  a  screw  fitting  into  a  slot  on  the  upper  blade  and  a  hole 
in  the  lower.  In  the  English  forceps  the  lock  is  reduced  to  slanting 
surfaces  corresponding  to  each  other  and  a  projecting  wing  (Fig.  429). 
The  German  lock  is  a  combination  of  the  two,  having  the  same  slant- 


FiG.  429. 


J.  Y.  Simpson's  forceps. 


ing  surfaces  as  the  English  and  a  button  on  the  lower  branch  corre- 
sponding to  a  slot  in  the  upper  (Figs.  430,  431). 

The  shank  is  a  stout,  angular  or  cylindrical  part  forming  the  connec- 
tion between  the  handle  and  the  blade.    The  blade  is  a  spoon-shaped, 


598 


OBSTETRIC    OPERATIONS. 


flat  part,  which  on  most  forceps  has  a  large  pear-shaped  opening, 
called  the  fenestra.  As  the  blades  are  made  to  grasp  the  fetal  head, 
and  come  in  direct  contact  with  the  uterus,  vagina,  and  vulva  of  the 


Fig.  430. 


Xaegele's  forceps. 
Fig.  431. 


Lock  of  the  same. 


mother,  all  sharp  edges  should  be  avoided.  The  instrument  should 
be  long  enough  to  seize  the  head  at  the  superior  strait,  and  strong 
enough  to  stand  the  resistance  of  a  fetal  head  and  a  contracted 
pelvis,  but  at  the  same  time  not  unnecessarily  large  and  heavy,  as  this 


Fig.  432. 


Elliott's  forceps. 


makes  its  application  more  difficult,  tempts  the  accoucheur  to  use 
undue  force,  and  increases  the  weight  of  his  satchel. 

The  forceps  most  used  in  America  are  Sir  James  Y.  Simpson's 
(Fig.  429),  EUiotfs  (Fig.  432),  and  Hodge's  (Fig.  433). 

Elliott's  forceps  has  in  the  handle  a  pin  which  can  be  made  longer 


FORCEPS    DELIVERY. 


599 


or  shorter  by  means  of  a  screw.  Its  object  is  to  prevent  too  great 
compression  of  the  head.  The  writer  may,  however,  state  that  the 
only  fracture  of  the  skull  which  has  occurred  in  his  practice  happened 
while  using  this  instrument.  Hodge's  forceps  is  much  like  Levret's. 
It  is  all  made  of  metal,  locks  with  a  screw,  has  large  fenestr?e,  and  the 
handles  end  in  long,  curved  wings.  On  account  of  the  large  blades 
it  gives  an  excellent  grip,  but  is  for  the  same  reason  so  much  more 
difficult  to  apply  and  so  much  more  dangerous  for  the  mother. 

Of  this  class  of  forceps  the  one  I  recommend  is  J.  Y.  Simpson's.  It 
is  fourteen  inches  long  and  has  a  moderate  pelvic  curvature  and  rather 
small  blades.  It  has,  of  course,  the  English  lock.  The  shanks  are 
separated  so  far  from  each  other  that  a  finger  may  be  placed  between 
them  for  pressure  against  the  lock,  if  desired.  The  handles  have 
wings  at  the  distal  end,  each  to  support  one  finger  of  the  right  hand, 
and  four  lateral  indentations  for  the  fingers  of  the  left  hand. 

Fig.  433. 


Hodge's  forceps. 


A  new  era  in  the  history  of  the  forceps  begins  in  1877,  when 
Tarnier,  of  Paris,  discarded  all  traction  on  the  handles,  which  he 
only  used  for  applying  the  instrument,  whereas  the  traction  was 
exercised  on  special  traction-rods  articulating  with  the  base  of  the 
blades.  At  the  distal  end  of  the  handles  he  put  a  screw,  which 
with  one  end  turns  on  a  pivot  fastened  to  the  right  branch,  while 
the  other  end  may  be  placed  in  a  clasp,  in  which  it  is  fastened  by 
turning  a  wing-nut. 

The  inventor  later  modified  his  instrument  considerably,  but  the 
principle  remains  the  same.  The  idea  is  to  use  the  handles  as  an 
index,  showing  in  what  direction  the  traction  shall  be  made ;  and  to 
execute  the  traction  by  means  of  separate  traction-rods.  The  lever- 
screw  is  not  destined  to  compress  the  head,  but  to  maintain  the 
pressure  which  by  manual  compression  is  found  necessary  to  keep 
the  grasp  on  the  head.  The  Tarnier  forceps  (Figs.  434,  435)  has  two 
traction-rods  that  are  fastened  to  the  blades  and  end  behind  in  hooks 
which  enter  the  manubrium.     The  latter  consists  of  an  upper  part 


600 


OBSTETRIC    OPERATIONS. 


with  a  strong  perineal  curvature  and  a  lower  transverse  bar,  which 
rotates  in  all  directions  around  the  former,  allowing  traction  to  be 
made  however  the  forceps  is  applied.  The  upper  part  is  kept  at  a 
distance  of  one  centimetre  from  the  branches,  and  traction  is  only- 
exercised  on  the  transverse  bar. 

In    the    writer's    opinion,    Tarnier's  instrument  is  unnecessarily- 
heavy  and  complicated,  and  is  even  apt  to  fall  apart  while  being  han- 

FiG.  434. 


Tarnier's  forceps  held  as  used  for  traction. 

died.  In  this  country  it  was  hailed  as  a  valuable  improvement  by 
the  late  Dr.  W.  T.  Lusk,  who  improved  the  articulation  between  the 
traction-rods  and  the  handle. 

In  Scotland  it  gave  birth  to  A.  R.  Simpson's  axis-traction  forceps, 
and  in  Vienna  it  was  modified  by  Breus  according  to  the  views  of  his 

Fig.  435. 


The  same  without  the  traction-handle. 


chief,  Carl  Braun.  In  France  it  was  severely  criticised  by  Pajot,  but, 
in  view  of  the  great  rivalry  among  Parisian  authorities  in  the  same 
line,  that  ought  not  to  have  too  much  weight.  In  Germany  they  are 
opposed  to  the  instrument,  but  national  prejudice  has  doubtless  influ- 
enced the  leaders.     In  America  the  instrument  is  little  known.     If 


FORCEPS    DELIVERY.  601 

the  profession  knew  it  better,  they  could  hardly  fail  to  adopt  it,  driven 
by  the  American  mechanical  genius  and  love  of  novelties. 

The  high  price  of  the  instrument  when  first  brought  out,  the 
erroneous  conception  that  it  was  adapted  only  for  special  and  rare 
cases,  and  the  fact  that  young  American  physicians  who  study  in 
Europe  much  more  frequently  choose  Germany  than  France  for  their 
temporary  residence,  may  all  have  contrDDuted  to  the  indolence 
shown  by  the  profession  at  large  towards  an  instrument  which  other- 
wise would  have  strong  claims  on  their  interest  and  support.  Per- 
sonally the  author  has  little  experience  with  tlie  Tarnier  instrument, 
but,  as  stated  above,  he  has  used  Smipson's  axis-traction  forceps 
for  all  purposes  since  its  invention,  and  that  instrument  is  only  a 
practical  simplification  of  Tarnier's.  In  the  writer's  opinion  this  is 
the  forceps  of  our  age,  and  the  old  forceps  without  traction-rods  is  an 
inferior  instrument  which  should  be  superseded  by  the  more  perfect 
one  which  has  been  evolved  from  it.  In  my  eyes  the  new  instrument 
has  two  great  advantages  over  the  old :  it  substitutes  mechanism  for 
judgment,  dexterity,  and  experience,  which  in  the  nature  of  things  can 
only  be  in  the  possession  of  a  few  favored  ones,  while  nearly  every 
practitioner  of  medicine  at  some  stage  of  his  evolution  is  called  upon 
to  use  the  forceps.  Secondly,  it  is  in  a  wonderful  degree  a  labor- 
saving  machine.  The  application  of  the  forceps  is  exactly  the  same 
whether  we  use  the  old  or  the  new  instrument,  or  the  difference  is  at 
least  so  insignificant  that  it  may  be  left  out  of  consideration.  Any- 
body who  is  competent  to  apply  the  old  instrument  can  apply  the 
Tarnier  or  the  Simpson  instrument.  But  as  soon  as  we  come  to 
the  traction — that  is  to  say,  to  the  real  use  of  the  instrument — there 
is  the  greatest  difference. 

With  the  old  instrument  the  accoucheur  has  to  fmd  out  where  the 
head  is  in  the  parturient  canal  and  constantly  change  the  direction  of 
the  traction.  If  he  pulls  on  the  handles  in  a  happy-go-lucky  way,  he 
will  waste  much  of  his  force  by  pressing  the  head  against  the  symphy- 
sis pubis,  and  he  will  be  likely  to  bruise  and  tear  the  soft  parts  of  the 
parturient  canal  or  even  cause  strong  ligaments  to  rupture  or  bones  to 
break.  How  difficult  it  is  to  pull  in  the  right  direction  appears  from 
the  very  different  ways  in  which  different  authors  recommend  to 
place  the  hands  on  the  forceps.  With  the  new  instrument  a  mere 
tyro  can  perform  a  forceps  extraction  properly.  He  has  only  to  fol- 
low the  rule  of  keeping  the  traction-rods  at  the  distance  of  one  centi- 
metre from  the  shanks  of  the  forceps  of  Tarnier's  instrument,  and 
hold  them  in  contact  with  the  shanks  in  using  Simpson's  axis-traction 
forceps.  Nothing  could  be  simpler.  As  long  as  the  accoucheur  fol- 
lows the  rules,  he  is  sure  to  pull  in  the  right  direction. 

The  value  of  the  new  instrument  as  a  labor-saving  machine  is 


g02  OBSTETRIC    OPERATIONS., 

very  marked,  and  must  particularly  appeal  to  men  advanced  in  age 
and  to  female  practitioners.  No  force  being  lost,  and  the  adaptation 
of  the  hands  to  the  handle  of  the  traction-rods  being  so  simple  and  so 
advantageous,  a  person  of  average  strength  is  able  to  perform  a  for- 
ceps delivery  without  overtaxing  himself  and  without  being  tempted 
to  resort  to  an  irregular  and  sudden  display  of  force,  involving  injury 
to  the  patient  and  exhaustion  of  the  physician.  A.  R.  Simpson's  axis- 
traction  forceps  (Fig.  425)  is  essentially  the  J.  Y.  Simpson  forceps  with 
addition  of  the  traction-apparatus  and  the  retention-screw  at  the  distal 
end  of  the  application-handles.  Since  these  handles  are  not  used  for 
traction,  the  wings  and  indentations  have  been  left  out.  Two  slender, 
curved  traction-rods  are  fastened  to  the  outside  of  the  blades,  just  be- 
low the  fenestrse,  where  they  are  retained  by  a  scre.w  and  nut  buried 
in  the  thickness  of  the  metal  without  forming  any  protrusion  on  the 
inside  of  the  blade.  The  left  rod  is  at  its  posterior  end  riveted  to  a 
little  triangular  plate.  The  right  rod  has  at  its  posterior  end  a  little 
button  which  fits  loosely  into  a  hole  and  slot  on  the  same  plate  to 
which  the  left  rod  is  riveted.  At  the  posterior  end  of  the  plate  there 
is  another  rivet  allowing  a  limited  degree  of  lateral  rotation  to  com- 
pensate the  deviation  caused  by  the  entrance  of  the  above-mentioned 
button  into  the  slot.  Around  this  rivet  moves  a  piece  of  steel  which 
at  the  other  end  perforates  the  middle  of  the  traction-handle,  a  cylin- 
drical bar  which  rotates  in  a  complete  circle  at  right  angles  to  the 
pivot  (Fig.  426). 

Simpson's  instrument  is,  in  my  opinion,  an  improvement  on  the 
Tarnier  forceps.  It  is  lighter.  There  are  no  loose  pieces  to  get  out 
of  order  or  become  lost.  The  traction-rods  are  fastened  to  the 
blades,  and  still  they  may  be  removed  for  cleaning  after  the  forceps 
has  been  used.  The  traction-handle  is  riveted  permanently  to  the 
left  traction-rod.  The  instrument  is  cheaper.  There  ought  indeed 
to  be  a  difference  of  only  a  few  dollars  in  the  price  of  an  old-fash- 
ioned forceps  and  the  modern  instrument. 

In  the  course  of  time  Professor  Simpson  has  made  such  modifica- 
tions in  his  forceps  as  were  needed  in  order  to  comply  more  strictly 
with  the  demands  of  aseptic  obstetrics.  The  new  model  is  represented 
in  Figs.  436  and  437.  The  wooden  bar  has  given  way  for  one  of 
metal,  the  screw-nuts  have  been  replaced  by  hooks  and  slots,  and  the 
connection  between  the  traction-rods  and  the  handle  has  been  im- 
proved so  as  to  increase  solidity  and  avoid  loss  of  force.  So  much 
gain  must  console  one  for  no  longer  having  all  parts  of  the  instru- 
ment fastened  to  the  two  branches. 

Action  of  the  Forceps. — The  forceps  is  chiefly  a  tractor.  The  head 
once  seized,  the  accoucheur  aims  at  pulling  it  out  in  the  direction  of 
the  axis  of  the  pelvis. 


Fig.  406. — A.  R.  SimpMiu'is  axis-traftioii  I'oreeiis,  new  model. 


I''l(;,  liiT.— I 'iiiiii ■Ill   jiMilsuf  I  lie- same. 


FORCEPS    DELIVERY.  603 

Traction  may  be  steady,  rocking,  or  rotatory.  The  steady  traction 
consists  in  pulling  the  head  as  nearly  as  possible  in  the  line  of  the 
axis  of  the  pelvis.  With  the  axis-traction  forceps  this  is  accomplished 
by  keeping  the  traction-rods  just  in  contact  with  the  shanks  of  the 
forceps,  thus  using  the  forceps  itself  as  an  indicator  of  the  direction. 
With  the  old  forceps  this  is  a  point  that  needs  much  attention.  In  a 
general  way,  we  may  say  that  when  the  head  is  at  the  brim,  traction 
should  be  made  in  the  direction  of  the  axis  of  the  brim ;  in  other 
words,  that  the  direction  of  the  line  of  traction  is  backward  towards 
the  perineum.  When  the  head  is  in  the  cavity  of  the  pelvis,  traction 
should  be  made  horizontally  forward  towards  the  accoucheur ;  and 
when  the  head  is  at  the  outlet,  the  direction  is  forward  and  upward, 
the  patient  lying  on  her  back.  But  it  will  easily  be  seen  that  these 
three  directions  correspond  only  to  three  points  of  the  road  to  be 
traversed,  and  that  there  are  innumerable  transitions  between  them. 
The  nearest  we  can  come  to  a  rule  is  to  say  that  when  the  forceps  is 
well  applied,  traction  should  be  made  in  the  direction  of  the  handles. 

In  the  rocking,  or  pendulum,  traction,  the  forceps,  while  being 
pulled  upon,  is  simultaneously  moved  a  little  from  side  to  side. 
Opinions  among  accoucheurs,  even  before  we  had  the  axis-traction 
forceps,  varied  much  as  to  the  value  of  this  rocking  movement. 
Its  defenders  said  it  diminished  friction,  and  pointed  to  the  way  in 
which  we  remove  a  tight-fitting  ring  from  a  finger  or  pull  a  cork 
with  the  fingers  from  a  bottle.  In  both  cases  very  marked  benefit  is 
derived  from  an  alternating  lateral  movement.  But  those  who  were 
opposed  to  it  said  that  if  a  nail  has  been  driven  into  a  costly  table,  we 
will  try  to  seize  it  with  a  pair  of  pincers  as  accurately  as  possible  at 
right  angles  and  pull  in  a  straight  line,  without  side  movements,  in 
order  to  do  as  little  damage  to  the  surrounding  parts  as  possible. 
The  writer  would  add  that  he  has  found  the  rocking  movement  very 
serviceable  when  the  head  is  low  down,  and  that,  executed  with  care, 
it  does  not  do  any  harm,  but  it  is  undeniable  that  the  perineum  is 
more  liable  to  suffer  than  by  the  steady  traction. 

The  rotatoi-y  movements  are  not  to  be  recommended,  as  they 
may  make  the  forceps  slip  and  injure  the  parturient  canal,  while  they 
have  no  advantage  over  the  rocking  movement. 

A  secondary  action  of  the  old  forceps  is  that  of  a  lever.  It  may 
be  used  as  a  lever  of  the  first  class,  the  power  being  at  the  handles, 
the  fulcrum  at  the  lock,  and  the  weight  at  the  blades.  But  generally 
it  is  a  lever  of  the  second  class,  the  power  being  at  the  handles,  the 
fulcrum  at  the  ends  of  the  blades,  and  the  weight  between  the  two. 
This  leverage  comes  into  play  when  we  use  the  old  forceps  and  make 
so-called  rocking  traction, — that  is,  move  the  handles  from  side  to 
side. 


604  OBSTETRIC    OPERATIONS. 

Leverage  is  lost  in  using  Tarnier's  forceps,  but  this  loss  is  amply- 
compensated  by  the  much-improved  traction.  With  Simpson's  for- 
ceps I  find  it  quite  feasible  to  make  some  pendulum  movements. 

A  third  action  is  that  of  a  compressor.  A  certain  degree  of  com- 
pression is  necessary  in  order  not  to  lose  the  grip  on  the  head ;  but, 
since  the  ordinary  forceps  all  lie  in  the  side  of  the  pelvis,  and  the  con- 
traction to  overcome  which  they  are  used  is  chiefly  found  in  the  an- 
teroposterior direction,  by  compressing  the  head  we  would  only  in- 
crease its  dimensions  in  the  sagittal  plane.  Compression  may  also 
injure  the  foetus,  and,  far  from  being  a  goal  the  attainment  of  which 
is  to  be  sought,  it  is  a  danger  and  an  inconvenience,  to  be  limited  as 
much  as  possible.  For  this  very  purpose  the  lock  is  always  placed 
nearer  to  the  proximal  end  than  to  the  distal  end. 

It  has  been  claimed  that  the  forceps  has  a  fourth  action,  called 
the  dynamic.  The  mere  presence  of  the  forceps  in  the  genital  canal 
is  said  to  call  forth  a  reflex  action,  and  thereby  increase  labor-pains, 
and  thus  indirectly  further  delivery  ;  but,  if  at  all  present,  this  action 
is  of  very  secondary  importance.  As  the  chief  action  of  the  forceps, 
there  remains,  then,  that  of  traction. 

The  forceps  may  also  be  used  to  change  the  position  of  the  head. 
For  this  purpose  a  straight  forceps  is  best,  but  one  with  a  slight  curve 
may  also  be  used. 

Finally,  the  forceps  may  be  used  for  steadying  the  head  during  crani- 
otomy ;  but,  as  a  rule,  it  is  not  necessary  to  use  it  for  this  purpose. 

Indications  for  the  Use  of  the  Forceps. — These  are  (1)  deficient  uter- 
ine contractions,  (2)  disproportion  between  the  size  of  the  head  and 
the  pelvis,  (3)  unfavorable  presentations  or  positions,  (4)  danger  to 
mother  or  foetus,  and  (5)  torn-off  head. 

The  forceps  is  most  commonly  used  when  labor-pains  are  too 
weak  to  finish  the  expulsion  of  the  foetus  by  nature's  sole  efforts 
(p.  357).  Under  this  indication  the  forceps,  as  a  rule,  is  used  when 
the  head  is  in  the  cavity  of  the  pelvis  or  presses  on  the  pelvic  floor. 
This  was,  in  the  beginning,  the  only  use  made  of  the  instrument,  and 
the  indication  could  be  fulfilled  by  the  short,  straight  forceps. 

In  describing  the  use  of  the  forceps  for  mechanical  disproportion, 
it  is  commonly  taken  for  granted  that  the  foetus  is  of  normal  dimen- 
sions and  the  rules  apply  only  to  the  maternal  pelvis  ;  but  it  is  evident 
that  similar  difficulties  arise  whether  the  parturient  canal  is  abnor- 
mally narrow  or  the  body  that  shall  pass  through  it  is  too  large.  In 
consultation  practice  the  writer  has  often  noticed  that  this  point  is 
overlooked.  The  attending  physician  reports  that  there  are  good 
labor-pains,  that  the  pelvis  seems  to  have  the  normal  dimensions,  but 
that  the  os  will  not  dilate.  In  many  such  cases  the  foetus  is  too  large 
in  proportion  to  the  pelvis  through  which  it  must  pass. 


FORCEPS    DELIVERY.  605 

The  different  kinds  of  excessive  size  of  tlie  foetus  have  been 
described  above  (p.  397  et  seq.). 

Supposing,  then,  we  have  to  deal  with  a  normal  fostus,  the  most 
common  condition  of  the  parturient  canal  calling  for  the  application 
of  the  forceps  is  a  contracted  pelvis  (p.  436  ct  seq.).  But  the  accou- 
cheur must  bear  in  mind  that  the  forceps  should  not  be  used  if  the 
true  conjugate  is  below  3  inches  (7|  centimetres)  in  a  flat  pelvis  or 
3J  inches  (8i^  centimetres)  in  a  generally  contracted  pelvis  (p.  463), 
unless  there  are  particularly  favorable  circumstances  present — an 
exceptionally  small  foetus  and  good  labor-pains — when  the  limit  may 
be  brought  down  to  2|  inches  (7  centimetres)  for  the  flat  and  to  3 
inches  (7|  centimetres)  for  the  generally  contracted  pelvis.  In  all 
these  cases  it  is  supposed  that  the  vertex  presents  and  the  occiput 
turns  forward.  In  occipitoposterior  or  in  brow  or  face  presentations 
exceptional  space  is  required  for  a  successful  forceps  operation.  If 
the  true  conjugate  measures  less  than  2f  inches  (7  centimetres),  the 
delivery  should  under  no  circumstances  be  tried  by  means  of  the 
forceps. 

Occipitoposterior  position  (p.  362),  occipitolateral  position  (p.  365), 
face  presentation  (p.  367),  brow  presentation  (p.  364),  often  demand 
the  aid  of  the  forceps. 

In  breech  presentation  the  forceps  is  rarely  used.  It  may,  how- 
ever, be  applied  to  the  after-coming  head  (p.  385) ;  but,  as  a  rule, 
manual  extraction  is  preferable  as  simpler  and  more  expeditious.  If 
the  legs  are  extended  in  front  of  the  body  of  the  foetus,  and  the 
breech  is  too  high  up  in  the  parturient  canal,  the  forceps  may  be  ap- 
plied over  the  sacrum  and  the  posterior  surface  of  the  thighs  or  along 
the  outer  surface  of  the  thighs  (p.  390). 

Dangerous  conditions  of  the  mother  that  call  for  forceps  delivery 
are  especially  hemorrhage,  eclampsia,  rupture  of  the  uterus,  strangu- 
lated hernia,  fever,  or  exhaustion. 

In  regard  to  the  fptus,  the  alarm  signals  consist  in  slowness  and 
weakness  of  the  pulse  and  expulsion  of  meconium  in  head  presenta- 
tion, while  in  breech  presentation  the  latter  is  of  less  importance, 
since  it  simply  may  be  due  to  mechanical  compression  of  the  bowels. 
Prolapse  of  the  cord  is  particularly  dangerous  (p.  414). 

In  cases  of  avulsion  of  the  head  the  forceps  is  not  the  real  instru- 
ment wanted,  more  efficient  help  being  obtainable  from  the  cephalo- 
tribe  or  the  cranioclast.  But  if  these  instruments  are  not  available, 
the  forceps  combined  with  craniotomy  may  be  used  as  a  welcome 
substitute  (p.  564). 

Conditions  for  the  Use  of  the  Forceps. — Even  when  following  the 
above-mentioned  indications,  the  forceps  should  not  be  used  unless 
certain  conditions  are  present.     First  of  all,  the  membranes  must  have 


606  OBSTETRIC    OPERATIONS. 

broken  or  have  been  ruptured,  so  that  the  forceps  can  be  applied 
directly  to  the  head  and  not  to  the  outside  of  the  ovum,  for  in  the 
latter  case  not  only  the  grip  would  be  less  firm,  but  we  might  tear 
the  placenta  from  the  uterus  and  cause  a  perhaps  fatal  hemorrhage. 

Secondly,  the  os  should  be  fully  dilated,  be  it  by  nature's  sole 
efforts  or  by  one  or  more  of  the  means  described  above  (p.  583).  If 
the  indication  for  terminatiug  labor  is  very  urgent,  this  condition  may, 
however,  be  dispensed  with  and  the  necessary  space  be  obtained  by 
means  of  incisions  in  the  circumference  of  the  os  (p.  588). 

Thirdly,  the  head  should  be  engaged  in  the  brim  of  the  pelvis ; 
that  is  to  say,  so  large  a  portion  of  the  head  should  have  passed 
the  superior 'strait  that  the  head  is  fastened  there.  As  long  as  the 
head  is  freely  movable  above  the  brim,  it  is  not  a  fit  object  for  for- 
ceps extraction ;  podalic  version  is  the  operation  called  for.  If  the 
forceps  is  used  to  seize  the  head  above  tlie  brim,  the  head  will  turn 
so  as  to  be  grasped  more  or  less  laterally,  and  that  os  frontis  which 
is  turned  backward  will  be  pressed  forcibly  against  the  promontory 
and  be  liable  to  become  fractured  (p.  460).  For  the  mother  there 
is  the  danger  of  great  bruising  of  the  pelvic  walls  with  subsequent 
inflammation,  gangrene,  or  paralysis,  and  of  the  forceps  slipping,  by 
which  serious  wounds  may  be  inflicted.  But  it  is  fair  to  add  that 
the  engagement  of  the  head  is  not  recognized  as  a  condition  by  all, 
some  obstetricians  of.  note  preferring  the  forceps  to  version  even  if 
the  head  is  movable  above  the  brim.  The  accoucheur  may  try  by 
direct  pressure  on  the  head  to  further  its  engagement,  and  if  success- 
ful apply  the  forceps  (p.  589). 

Fourthly,  the  position  should  be  distinctly  made  out,  so  as  to  be 
able  to  apply  the  instrument  intelligently  and  to  pull  in  the  proper 
direction. 

Modus  Operandi. — If  a  difficult  forceps  extraction  is  to  be  antici- 
pated, it  is  better  to  place  the  patient  on  a  table  (p.  590).  For  the 
more  common  operations,  it  suffices  to  place  the  patient  across  the 
bed.  It  is  advisable  to  shorten  the  hairs  growing  on  the  labia  majora 
and  the  nearest  of  those  springing  from  the  mons  Veneris  with  scis- 
sors. The  vagina  is  cleaned  with  an  antiseptic  douche.  The  patient 
is  anaesthetized  (p.  591),  unless  she  prefers  to  stand  the  pain,  which 
is  preferable  in  so  far  as  then  the  uterine  contractions  may  work  in 
conjunction  with  the  force  exercised  by  the  accoucheur.  The  patient 
should,  as  a  rule,  occupy  the  dorsal  position,  with  bent,  raised,  and 
moderately  separated  knees.  This,  at  least,  is  the  custom  in  America 
and  on  the  continent  of  Europe.  In  England  the  accoucheurs  prefer 
to  operate  with  the  patient  lying  on  her  left  side.  But  in  difficult 
cases  they  have  recourse  to  the  dorsal  position  ;  and,  vice  versa,  those 
who  usually  extract  on  the  back  may  occasionally  derive  benefit  by 


FORCEPS   DELIVERY.  607 

placing  the  patient  on  her  left  side.    In  such  cases  the  hanging  posture 
(p.  592)  may  also  be  tried. 

Before  introducing  the  forceps,  the  bladder  should  be  emptied 
with  a  catheter.  To  overlook  this  is  a  grave  fault  which  not  only  may 
render  the  operation  more  difficult,  but  may  have  the  most  serious 
consequences,  such  as  rupture  of  the'  uterus,  the  formation  of  a  vesico- 
vaginal fistula,  etc.  When  the  head  is  more  or  less  engaged,  it  may 
be  quite  difficult  to  pass  the  catheter,  the  urethra  being  compressed 
between  the  head  and  the  symphysis  pubis.  Glass  catheters  are  ob- 
jectionable, because  they  may  break  and  wound  the  patient.  Male 
catheters  of  white-metal  are  soft  and  easily  bent  to  answer  any  curva- 
ture. Flexible  catheters  are  good,  but  should  be  introduced  without 
the  stylet.  They  do  not  stand  boiling,  and  become  rough  in  solu- 
tions of  carbolic  acid,  creolin,  or  lysol.  They  should,  therefore,  be 
disinfected  by  immersion  in  bichloride  of  mercury  solution.  Some- 
times a  soft  rubber  catheter  will  worm  its  way  into  the  bladder  bet- 
ter than  anything  else,  and  it  stands  boiling  with  soda  well.  If  the 
catheter  meets  resistance,  the  accoucheur  should  beware  of  using 
force,  lest  he  perforate  the  urethra.  In  such  cases  another  instru- 
ment should  be  tried,  and  often  it  is  possible  by  pressing  the  head  of 
the  foetus  upward  in  the  direction  of  the  pelvic  axis  with  the  left 
hand  to  obtain  the  room  necessary  for  the  passage  of  the  catheter 
with  the  right. 

The  forceps  should  be  sterilized  by  boiling  in  soda  solution  (p. 
594)  for  a  few  minutes.  It  is  lubricated  by  immersion  in  creolin  or 
lysol  solution.  The  obstetrician  stands  at  the  end  of  the  table  or  sits 
at  the  bedside  on  a  chair,  as  described  on  page  590.  The  left  or  lower 
blade  is  introduced  first.  It  is  seized  with  the  left  hand  like  a  pen,  and 
held  between  the  thumb  on  the  inside  of  the  handle  and  the  index- 
finger  above  and  the  middle  finger  below  the  wing.  The  two  other 
fingers  may  either  be  held  parallel  to  the  middle  finger  or  bent  against 
the  hollow  of  the  hand  (Fig.  438).  The  beginner  may  derive  some 
benefit  by  retaining  the  rule  in  his  memory  that  everything  shall  be 
left  except  the  obstetrician.  The  index  and  middle  finger  of  the  right 
hand  are  stretched  out,  introduced  inside  of  the  os,  and  applied  as 
high  up  as  possible  on  the  head.  Next,  the  point  of  the  left  blade  is 
held  against  the  base  of  the  volar  surface  of  the  two  fingers,  which 
are  used  as  a  guide  for  the  instrument.  At  first  the  handle  is  held  in 
the  direction  of  the  right  groin,  and  gradually  it  is  lifted  and  brought 
forward  and  over  towards  the  left  side  of  the  woman,  and,  finally, 
backv\^ard.  During  this  whole  introduction  the  point  of  the  forceps 
is  slid  along  the  furrow  between  the  two  fingers. 

When  the  forceps  reaches  the  head,  the  accoucheur  should  in  his 
mind's  eye  see  the  cephalic  and  the  pelvic  curvature,  and  guide  the 


608 


OBSTETRIC    OPERATIONS. 


instrument  in  the  direction  of  tlie  combination  of  the  two.  As  a  rule, 
he  tries  to  keep  it  at  the  end  of  the  transverse  diameter  of  the  pelvis, 
but  often  the  instrument  enters  a  httle  farther  back.  He  then  seizes 
the  handle  with  the  full  hand,  and  by  a  rotatory  movement  brings  it 
forward  until  it  lies  in  the  transverse  diameter.  He  then  requests 
an  assistant  to  take  hold  of  the  -handle,  passing  his  hand  under  the 
patient's  left  knee,  and  hold  it  in  the  same  position,  while  he  applies 
the  second,  upper,  or  right  branch  of  the  forceps.     This  is  a  little 

Fig.  438. 


Left  branch  of  forceps  guided  by  right  hand. 


more  difficult  to  do  than  to  apply  the  first,  there  being  now  less  space. 
The  second  branch  is  applied  in  exactly  the  same  way  as  the  first, 
only  it  is  seized  with  the  right  hand  and  inserted  into  the  right  side. 
When  both  branches  are  introduced,  the  accoucheur  holds  each  of 
them  with  the  full  hand,  and  makes  such  changes  in  their  position 
that  they  can  be  easily  locked^ — that  is  to  say,  that  the  two  halves  of 
the  lock  are  brought  in  perfect  contact.  If  he  does  not  succeed  in 
this,  the  second  branch  should  be  withdrawn  and  reintroduced  in  a 
more  appropriate  direction.  Before  locking  the  forceps  the  accou- 
cheur should  pull  gently  on  the  branches,  to  satisfy  himself  that  their 
cephalic   curvature   corresponds  to  the  head.     In  pushing  the  right 


FORCEPS    DELIVERY.  609 

branch  into  the  left  he  should  use  his  index-fmgers  to  hold  pubic 
hairs  and  folds  of  the  vagina  out  of  the  way.  When  the  forceps  is 
locked  the  operator  should  again  make  a  slight  traction  on  them,  to 
satisfy  himself  that  the  instrument  lies  properly. 

During  traction  the  handles  are  kept  together  by  the  left  hand 
passed  around  them,  the  back  of  the  hand  pointing  downward  and 
the  thumb  lying  above  them.  The  chief  traction  is  made  with  the 
right  hand,  the  index  and  the  middle  fmger  pulling  on  the  wings,  the 
thumb  resting  below  the  wing  of  the  left  branch  and  the  ring-fmger 
and  little  fmger  occupying  a  similar  position  under  the  right  wing  and 
the  fingers  of  the  left  hand  (Fig.  439).  Some  prefer,  however,  to 
apply  the  left  hand  at  right  angles  to  the  shanks  just  above  the  lock. 

Fig.  439. 


Mode  of  holding  forceps  during  traction. 

so  as  to  exercise  downward  pressure  with  the  ulnar  edge,  and  form 
a  fulcrum  around  which  the  instrument  moves  (Fig.  440). 

Before  beginning  to  pull  the  accoucheur  should  notice  how  much 
of  the  forceps  remains  outside  the  vulva,  where  the  lowest  point  of 
the  head  is  in  relation  to  the  parturient  canal  and  in  relation  to  the 
lowest  point  of  the  fenestra.  The  first  two  points  will  enable  him  to 
watch  the  progress  made  during  extraction,  and  the  last  will  warn 
him  in  time  if  the  forceps  begins  to  slip  off  from  the  head. 

The  direction  in  which  traction  is  to  be  made  depends  on  how  far 
the  head  has  descended  in  the  parturient  canal.  When  it  is  high  up, 
the  direction  is  downward  towards  the  perineum ;  when  it  is  in  the 
cavity,  the  direction  is  horizontal  towards  the  obstetrician ;  and  when 
it  is  at  the  outlet,  the  direction  is  straight  upward. 

If  the  woman  is  not  anaesthetized,  if  labor-pains  are  present,  and 
there  is  no  particular  hurry,  traction  should  be  made  during  the  pains 
and  interrupted  during  the  interval.  And  even  if  an  anaesthetic  is 
used,  traction  should  be  made  much  as  uterine  contraction  acts, — 
that  is  to   say,  it  should  begin  slowly,  then  increase  in  strength,  and 

39 


610 


OBSTETRIC    OPERATIONS. 


thereafter  again  slowly  decrease.  In  this  way  the  walls  of  the  geni- 
tal canal  are  gradually  prepared  to  let  the  foetus  pass,  and  the  foetus  is 
much  less  liable  to  be  injured.  Each  such  traction  should  last  about 
a  minute,  and  be  followed  by  a  pause,  during  which  the  forceps  is 
held  loosely,  so  as  to  allow  it  to  recede  partly  and  to  permit  the  head 
to  turn  inside  of  the  blades. 

During  the  tractions  and  in  the  intervals  it  is  well  frequently  to 
introduce  the  index-fmger  into  the  vagina  in  order  to  ascertain  how 
much  progress  has  been  made,  whether  a  swellmg  is  forming  on  the 
head,  or  the  blades  begin  to  slip. 

When  the  largest  circumference  of  the  head  is  at  the  rimapudendi, 
I  take  off  the  forceps  and  enucleate  the  head  by  pressure  through  the 
rectum,  as  described  above  (p.  193).     By  so  doing  we  gain  the  space 

Fig.  440. 


Another  way  of  holding'  the  forceps. 

occupied  by  the  forceps  and  the  head  may  be  brought  out  with  greater 
care  than  when  the  extraction  is  finished  with  the  forceps. 

Sudden  or  violent  movements  should  be  carefully  avoided.  The 
strength  of  a  man  of  ordinary  muscular  development  is  all  that  is 
required  and  can  be  borne  without  damage.  The  accoucheur  should 
use  only  his  arm  muscles,  and  not  employ  the  weight  of  his  body  as 
traction  force  by  throwing  himself  back,  whereby  he  loses  all  control 
over  the  instrument.  If  the  extraction  is  made  while  sitting,  only  a 
weak  man  should  brace  himself  by  pressing  one  foot  against  the  side 
of  the  bedstead,  never  both. 

During  traction  an  assistant  should  press  with  both  open  hands 
on  the  fundus,  so  as  to  push  the  foetus  against  the  brim  of  the  pelvis 
(p.  589). 


FORCEPS   DELIVERY,  611 

When  the  operatdr  wants  to  remove  the  forceps,  he  separates  its 
branches  by  openmg  the  lock  and  moves  the  handle  of  the  upper 
branch  in  a  circle  in  the  direction  of  the  left  groin.  When  this  branch 
is  withdrawn,  he  removes  the  left  branch  in  the  opposite  direction. 

When  the  head  is  born,  the  operation  proper  is  finished,  but  the 
same  conditions  which  indicated  the  use  of  the  forceps  may  call  for 
help  in  the  delivery  of  the  shoulders  and  the  rest  of  the  body.  In 
this  respect  pressure  from  above  may  again  offer  valuable  help.  But 
traction  from  below  is  often  rec{uired  in  addition.  The  head  may 
under  no  circumstances  be  used  for  pulling.  All  that  is  permissible 
is  to  seize  itbetw^een  the  two  flat  handsandalternatelypress.it  down- 
ward and  upward,  beginning  with  the  downward  motion.  As  soon 
as  feasible,  one  or  both  index-fingers  are  hooked  over  the  armpit.  The 
accoucheur  should  help  that  shoulder  out  first  which  is  lowest, — as  a 
rule,  the  anterior, — but  if  he  meets  with  resistance,  it  is  better  to  try 
the  other  first. 

If  the  cord  is  wound  around  the  neck,  it  is  liberated  as  in  normal 
deliveries  (p.  194). 

When  the  shoulders  have  appeared,  it  may  still  be  necessary  to 
pull  on  the  body  until  the  breech  has  passed,  after  which  the  lower  ex- 
tremities follow  easily.  At  this  stage  it  is  convenient  to  haul  the  patient 
a  little  back  from  the  edge  of  the  bed,  so  as  to  find  room  to  place  the 
baby  on  its  back  between  her  legs,  across  her  genitals.  If  the  child 
is  in  a  good  condition,  we  wait  to  tie  the  cord  until  it  has  cried  and 
the  pulsation  in  the  cord  stops ;  but  frequently  the  child  is  asphyctic, 
when  we  should  tie  and  cut  the  cord  without  delay  and  take  proper 
measures  for  its  revival  (p.  559),  while  an  assistant  holds  the  uterus 
of  the  mother  compressed  in  order  to  prevent  hemorrhage.  When 
the  accoucheur  is  through  with  the  child,  he  returns  to  the  mother, 
expresses  the  placenta  and  removes  the  membranes.  If  there  is  any 
tear  of  the  perineum,  which  is  quite  common  in  forceps  operations  on 
primiparse,  he  sutures  it,  and  finally  the  patient  is  cleaned  and  ban- 
daged as  in  normal  cases. 

How  the  Forceps  Grasps  the  Head. — As  stated  above,  as  a  rule, 
we  place  the  branches  of  the  forceps  laterally,  at  the  end  of  the  trans- 
verse diameter  of  the  pelvis.  Since  now  the  head  occupies  a  differ- 
ent position  in  relation  to  the  pelvis  as  it  descends,  passing  all  the 
way  from  the  transverse  to  the  anteroposterior  diameter,  it  will  of 
necessity  be  grasped  differently  by  the  forceps  at  different  depths  of 
the  parturient  canal.  If  it  were  grasped  right  in  the  beginning  of  its 
descent,  the  forceps  would  come  to  lie  with  one  branch  on  the  occiput 
and  the  other  on  the  face,  which  is  undesirable.  But  nearly  always 
the  long  axis  of  the  head  will  be  in  a  somewhat  oblique  diameter  of 
the  pelvis,  and  the  forceps,  adapting  itself  more  easily  to  the  sides  of 


612 


OBSTETRIC    OPERATIONS. 


the  head  than  to  the  occiput  and  face,  will  help  to  turn  it  into  the 
oblique  diameter.  When  under  these  circumstances  the  forceps  is 
applied  in  the  transverse  diameter  of  the  pelvis,  it  must  of  necessity 

Fig.  441. 


Fig.  442. 


Forceps  applied  to  head  at  brim. 

seize   the  head  obliquely,  one  branch  lying   on  the  temporal  and 
frontal  region  (Fig.  441),  touching  or  perhaps  even  surrounding  the 

eye,  and  the  other  covering  part  of 
the  parietal  and  occipital  bone  of 
the  opposite  side. 

On  the  other  hand,  when  the 
head  has  turned  into  the  antero- 
posterior diameter,  it  will  be  seized 
laterally,  the  fenestrse  surrounding 
the  parietal  eminence  and  the  ear 
(Fig.  442). 

If  the  head  is  low  doAvn,  but 
still  m  an  oblique  diameter,  the  for- 
ceps may  be  applied  to  these  por- 
tions of  the  head,  and  consequently 
be  placed  in  the  oblique  diameter 
of  the  pelvis,  from  which  position  it  will  rotate  towards  the  transverse 
diameter,  just  as  the  head  rotates  into  or  near  to  the  anteroposterior 
diameter  in  normal  deliveries. 


Forceps  on  head  at  outlet. 


FORCEPS   DELIVERY.  613 

For  clearness'  sake,  we  have  so  far  given  an  uninterrupted  de- 
scription of  the  forceps  operation  in  a  common  vertex  presentation, 
but  it  will  now  be  necessary  to  advert  to  some  difficulties  which  are 
frequently  met  with  in  this  operation. 

Even  in  cases  in  which  a  speedy  delivery  is  indicated,  the  opera- 
tor should  insert  the  forceps  deliberately  and  carefully.  If  its  point 
is  caught  by  folds  of  the  vagina  or  of  the  scalp,  he  should  beware  of 
pushing  on  the  instrument  until  he  with  his  fingers  has  removed  the 
obstacle. 

The  head  may  be  so  impacted — that  is,  in  such  close  contact  with 
the  sides  of  the  pelvic  wall — that  there  is  not  room  for  the  branches 
of  the  forceps  at  the  ends  of  the  transverse  diameter.  Then  the  first 
branch  should  be  introduced  farther  backward,  in  front  of  the  ilio- 
sacral  articulation,  where  there  is  more  space.  When  once  it  is 
inserted  it  is  generally  possible  by  small  movements  to  and  fro  to 
bring  it  forward  to  the  normal  place.  If  this  is  not  possible,  the 
second  blade  must  be  introduced  more  forward,  in  the  region  of  the 
iliopectineal  eminence,  in  order  to  correspond  to  the  first. 

Finding  more  space  behind,  the  blades  of  the  forceps  may  shde  in 
this  direction,  which  is  indicated  by  the  wings  turning  forward.  Then 
the  instrument  cannot  be  locked,  but,  as  said  above,  by  gentle  move- 
ments, the  accoucheur  will,  as  a  rule,  succeed  in  replacing  them  at 
the  end  of  the  transverse  diameter  of  the  pelvis.  For  this  purpose 
he  seizes  the  handles  with  the  full  hand  and  moves  them  backward 
in  the  direction  of  the  perineum,  and  imparts  simultaneously  a  rota- 
tory movement  to  them,  so  as  to  bring  the  wings  back. 

More  rarely  the  blades  deviate  forward,  when  the  wings  point 
backward.  Then  the  replacement  is  executed  by  lifting  the  handles 
and  rotating  them  forward. 

If  the  obstetrician  does  not  succeed  in  locking  the  forceps,  he 
must  remove  one  or  both  branches  and  apply  them  anew. 

In  judging  of  the  place  occupied  by  the  head  before  applying  the 
forceps  or  of  the  progress  made  during  traction,  the  operator  must 
beware  of  being  deceived  by  the  presence  or  formation  of  caput  suc- 
cedaneum,  which  may  make  him  believe  that  the  head  is  much  lower 
down  than  it  is  in  reality.  The  swelling  of  the  scalp,  being  softer 
than  the  skull,  is  more  elastic,  and  can  be  more  or  less  indented. 

After  the  forceps  has  been  locked,  it  may  show  a  tendency  to 
reopen.  This  shows  that  an  elastic  mass  is  seized  by  the  points  of  the 
forceps — namely,  that  they  press  on  the  neck  of  the  fcBtus,  which 
ought  to  be  avoided.  When  the  neck  is  seized  vdth  the  forceps, 
traction  is  made  on  the  head  and  trunk  together  as  one  object,  which 
impedes  the  movements  of  the  head.  The  forceps  may  also  do  harm 
by  compressing  the  cervical  blood-vessels,  or  the  umbilical  cord,  if  it 


614  OBSTETRIC    OPERATIONS. 

is  wound  around  the  neck,  or  may  fracture  the  clavicle.  Under  such 
circumstances  the  instrument  should  be  taken  out  and  reapplied  in 
another  direction,  depressing  or  lifting  the  handles  more  than  in  the 
first  attempt. 

During  traction  the  forceps  may  slip — that  is  to  say,  lose  its  grip 
on  the  head.  If  this  takes  place  suddenly,  the  operator  may  fall  on 
his  back,  holding  the  disengaged  instrument  in  his  hands,  a  disgrace- 
ful accident,  that  will  cover  the  accoucheur  with  blame  and  ridicule, 
and  may  inflict  serious  wounds  on  the  patient. 

The  slipping  may  be  perpendicular  or  horizontal.  It  is  called  per- 
pendicular if  the  forceps  slides  along  the  sides  of  the  head  more  or 
less  in  the  direction  of  the  pelvic  axis,  and  horizontal  if  the  blades 
deviate  forward  or  backward  in  the  pelvis.  The  cause  of  the  per- 
pendicular sliding  is  an  imperfect  application  of  the  forceps  to  the 
head.  If  too  small  a  part  of  the  head  is  seized,  the  instrument  will 
slide  down  when  traction  is  made.  The  same  will  happen  if  the  for- 
ceps is  used  on  the  head  of  an  immature  foetus  so  small  that  it  does 
not  fill  the  space  between  the  blades.  Traction  in  a  wrong  direction 
is  liable  to  produce  horizontal  sliding.  In  perpendicular  sliding  the 
distance  from  the  lower  end  of  the  fenestra  to  the  head  increases,  and 
the  handles  become  more  separated  from  each  other.  In  horizontal 
sliding  they  become,  on  the  contrary,  more  approximated.  When 
any  of  these  signs  warn  of  the  impending  danger  of  slipping,  the  con- 
dition should  be  cleared  up  by  a  vaginal  examination,  and  the  forceps 
reapplied. 

In  difficult  cases  it  may  not  be  sufficient  to  introduce  two  fingers 
into  the  vagina  as  a  guide  for  the  forceps.  Then  we  may  sometimes 
succeed  in  applying  it  by  using  all  four  fingers,  the  so-called  half- 
hand,  or  even  the  whole  hand. 

How  the  forceps  is  used  in  the  unusual  positions  and  presenta- 
tions has  been  described  under  the  treatment  of  each  of  them. 

Ajiplication  of  Simpsoii's  Axis-traction  Forceps. — For  introducing 
Simpson's  axis-traction  forceps,  the  traction-rods  are  pushed  forward 
in  front  of  the  shafts  and  held  together  with  the  handles.  The  for- 
ceps is  held  exactly  as  described  above.  When  both  branches  are  in 
place,  the  traction-rods  are  pushed  back  behind  the  shafts.  The  screw 
is  not  used  for  compressing  the  head,  but  for  holding  the  handles 
against  each  other,  and  is  turned  sufficiently  to  keep  them  in  place. 
In  the  interval  between  tractions  it  may  be  loosened.  After  the 
rods  have  been  brought  back  and  the  screw  is  in  place,  the  handle  is 
attached.  In  making  traction  the  traction-rods  should  be  in  contact 
with  the  shanks.  Traction  is  made  by  seizing  the  transverse  bar  with 
the  right  hand  from  above,  two  fingers  on  each  side  and  the  thumb 
below. 


FORCEPS   DELIVERY. 


615 


If  the  accoucheur  wishes  to  finish  the  whole  extraction  of  the 
head  with  the  axis-traction  forceps, — be  it  Tarnier's  or  Simpson's, — 
he  should  let  go  of  the  traction-handle  when  the  largest  circum- 
ference of  the  head  is  in  the  vulva,  and  hold  the  traction-rods 
together  with  the  shanks  of  the  forceps  with  the  full  right  hand,  the 
thumb  turning  upward.  By  so  doing  he  can  prevent  a  too  sudden 
escape  of  the  head  and  help  it  out  with  small,  cautious  movements 
(Fig.  443). 

Fig.  443. 


Axis-traction  forceps  held  with  full  hand  in  delivery  of  head. 


To  remove  the  forceps,  the  button  of  the  traction-rods  is  freed,  the 
screw  and  the  lock  are  opened,  and  the  branches  are  withdrawn  as  in 
using  the  old  forceps. 

High,,  Middle^  and  Low  Forceps  Operations. — If  the  forceps  is  ap- 
plied to  the  head  at  the  brim,  it  is  called  a  high  operation  ;  if  the  head 
is  at  the  outlet,  it  is  called  a  low  operation,  and  if  the  head  is  in  the 
cavity  of  the  pelvis,  it  is  called  a  middle  operation. 


616  OBSTETRIC    OPERATIONS. 

Ancesthesia. — Most  women  prefer  to  be  ansesthetized  for  a  forceps 
operation,  and,  as  the  pain  is  considerable,  it  is  proper  to  comply  with 
their  wish ;  but  if  the  patient  does  not  care  it  is  better  not  to  use 
an  angesthetic,  as  then  uterine  contractions  work  in  unison  with  the 
traction  exercised  by  the  accoucheur.  If  the  patient  is  very  weak 
and  the  speediest  delivery  is  indicated,  it  is  preferable  not  to  anaes- 
thetize her. 

Prognosis. — The  prognosis  in  forceps  operations  differs  much  in 
different  cases  according  to  the  indication  for  the  use  of  the  instru- 
ment. If  this  is  mere  inertia  uteri  and  the  head  is  low  down  in  the 
parturient  canal,  the  operation  is  easy,  and  the  prognosis  for  mother 
and  foetus  is  good.  But  if  there  is  a  disproportion  in  the  size  of  the 
pelvis  and  the  foetus,  if  there  is  an  unfavorable  presentation  or  posi- 
tion, and  if  the  presenting  part  is  still  high  up  in  the  pelvis,  the  ope- 
ration becomes  more  or  less  difficult,  dangerous,  or  impossible ;  but, 
upon  the  whole,  the  forceps  should  be  looked  upon  as  a  beneficent 
adjuvant  in  abnormal  labor. 

In  an  otherwise  excellent  text-book  of  obstetrics  of  recent  date, 
representing  one  of  the  German  university  clinics,  it  is  stated  that  the 
forceps  was  used  in  only  2.75  per  cent,  of  cases.  In  my  opinion  it  is 
called  for  three  times  as  often,  and  I  cannot  look  upon  it  as  "  a  dan- 
gerous instrument,"  but  it  should  be  used  only  when  indicated  and 
when  the  above-mentioned  conditions  are  present. 

Still,  it  is  undeniable  that  a  forceps  operation,  as  well  as  most  other 
operations,  is  accompanied  by  certain  dangers,  which  the  operator 
should  bear  in  mind.  For  the  mother  the  chief  dangers  consist  in 
contusions  and  lacerations  of  the  soft  parts  and  hemorrhage.  If  the 
forceps  is  applied  before  the  os  is  fully  dilated,  deep  lacerations  of  the 
cervix  may  occur.  The  convex  edge  of  the  blade  is  apt  to  wound 
the  posterior  wall  of  the  vagina.  The  perineum  is  often  more  or  less 
torn,  especially  in  prmiiparae,  but  with  proper  care  the  laceration  does 
not  extend  into  the  rectum  and  is  easily  repaired.  The  perineum  is 
particularly  liable  to  injury  if  the  head  is  totally  extracted  with  the 
forceps,  instead  of  using  enucleation,  as  we  recommend  whenever  it 
is  practicable. 

Pressure  against  the  walls  of  the  pelvis  may  result  in  the  forma- 
tion of  a  hsematoma  or  produce  gangrene.  When  it  implicates  the 
bladder  and  the  urethra,  it  may  cause  paralysis  of  the  sphincters  or 
detrusor,  with  incontinence  or  retention.  The  forceps  rarely  wounds 
the  base  of  the  bladder.  The  vesicovaginal  fistula  that  sometimes 
follows  forceps  operations  is  the  result  of  the  pressure  of  the  head 
against  the  symphysis.  This  contusion  leads  to  gangrene,  and  when 
the  mortified  plug  is  expelled  there  remains  a  fistula.  A  timely  use 
of  the  instrument  is  a  preventive  of  this  untoward  accident,  and  as  a 


FORCEPS   DELIVERY. 


617 


Fig.  444. 


matter  of  fact  vesicovaginal  fistulae  have  become  much  rarer  since  the 
forceps  is  used  more  frequently. 

Pressure  on  the  sacral  plexus  may  cause  paralysis  or  contracture 
of  the  legs,  but  it  would  be  unjust  to  blame  the  forceps  for  it.  Quite 
the  contrary,  it  is  well  known  that  a  greater  pressure  of  short  dura- 
tion causes  less  harm  than  a  protracted  one  of  lesser  degree.  It  is 
the  lack  of  space  and  not  the  forceps  that  causes  the  injury.  Rarely 
the  strong  ligaments  of  the  pelvis  are  ruptured  or  the  bones  broken. 

Serious  hemorrhage  may  immediately  follow  the  operation.  It  may 
be  due  to  deep  lacerations  of  the  cervix,  the  vagina,  or  the  perineum, 
or  it  may  come  from  the  interior  of  the  womb,  the  lower  part  of  the 
placenta  becoming  detached  and  uterine  contraction  being  deficient. 

There  are  also  dangers  for  the  foetus  in  forceps  extraction.  The 
soft  parts,  especially  the  scalp,  may  be  wounded,  and  by  neglect  of 
cleanliness  this  may  lead  to  erysipelas, 
cellulitis,  or  gangrene.  The  bones  of 
the  skull  may  be  fractured.  Intracra- 
nial hemorrhage  may  occur,  with  or 
without  such  fracture.  Blood  is  also 
sometimes  found  extravasated  in  the 
abdomen,  especially  in  the  suprarenal 
capsules. 

In  dressing  wounds  of  new-born 
children  the  accoucheur  should  abstain 
from  the  use  of  poisonous  substances, 
such  as  corrosive  sublimate,  carbolic 
acid,  or  iodoform.  But  saturated  solu- 
tion of  boric  acid  and  enzymol  diluted 
with  four  or  five  times  its  bulk  of 
water  are  safe  and  useful  in  keeping 
off  infection  and  promoting  granulation. 

If  the  blade  of  the  forceps  contunds 
the  trunk  of  the  facial  nerve,  the  child 
may  be  born  with  facial  paralysis  (Fig. 
444),  which  is  apt  to  scare  the  friends 
and  may  interfere  with  suckling,  but  otherwise  is  of  little  importance, 
as  the  distortion  usually  disappears  spontaneously  in  a  week  or  two. 
Some  think  that  the  compression  of  the  brain  during  a  difficult  forceps 
operation  may  be  the  cause  of  epilepsy  or  idiocy. 

The  Obstetric  Vectis. — Before  the  obstetric  forceps  was  known 
obstetricians  often  employed  an  instrument  called  a  vectis.  It  was 
much  like  one  blade  of  a  straight  forceps,  and  was  used  as  a  lever. 
It  has  nearly  everywhere  been  replaced  by  the  forceps,  and  may  be 
regarded  as  obsolete. 


Facial  paralysis  of  nert'-born  child. 
"(Ahlfeld.) 


(318  OBSTETRIC    OPERATIONS. 

CHAPTERXI. 

VERSION. 

Obstetric  version,  or  turning,  is  an  operation  by  which  the  foetus 
is  moved  around  its  transverse  axis  so  as  to  replace  tlie  presenting 
part  by  another  chief  portion  of  the  body. 

A  mere  correction  of  the  presentation,  as  when  we  change  a  brow 
presentation  into  a  vertex  or  a  face  presentation,  is  not  a  version.  Nor 
is  it  a  version  if  in  a  breech  presentation  we  pull  one  leg  down.  But  if 
we  substitute  the  head  or  the  breech  for  the  shoulder,  or  the  pelvic  end 
for  the  head,  then  we  turn  the  child  in  the  obstetric  sense  of  the  word. 

The  aim  is  to  bring  the  foetus  into  a  longitudinal  presentation  and 
make  its  head,  its  breech,  or  its  feet  occupy  the  os. 

According  to  this  difference  of  object  we  have  three  kinds  of 
version.  The  operation  is  distinguished  as  cejihalio  version  when  the 
head  is  made  to  present,  pelvic  version  when  the  breech  is  placed  at 
the  brim  of  the  pelvis,  and  podalio  version  when  an  artificial  footling 
presentation  is  substituted  for  a  head  or  a  cross  presentation. 

Version  may  be  accomplished  by  different  methods, — the  external 
method  and  the  internal  method.  The  latter  is  again  subdivided  into 
the  digital  and  manual  methods. 

External  version  is  performed  with  both  hands  outside  the  uterus ; 
in  internal  digital  version  one  or  two  fingers  enter  through  the  os,  and 
the  remainder  of  the  hand  lies  in  or  outside  of  the  vagina  ;  while  in 
internal  manual  version  the  whole  hand  is  inserted  into  the  uterus. 

§  1.  Version  by  the  external  method  may  be  executed  towards 
the  end  of  pregnancy  or  during  the  beginning  of  labor  before  there  is 
any  dilatation  of  the  cervix.  To  substitute  a  head  presentation  for  a 
breech  presentation  is  hardly  possible,  but  to  change  a  cross  presenta- 
tion into  a  longitudinal  presentation  by  this  method  is,  as  a  rule,  not 
difficult.  If  feasible,  we  bring  the  head  down  and  the  breech  up,  but 
if  that  cannot  be  done,  much  is  gained  by  changing  the  transverse 
presentation  into  a  pelvic  presentation. 

When  through  abdominal  and  vaginal  examination  we  have  found 
that  there  is  no  part  presenting,  and  that  the  head  lies  in  one  of  the 
sides  of  the  abdomen,  we  place  the  patient  on  her  back  with  mod- 
erately flexed  and  separated  lower  extremities,  so  as  to  have  as  little 
tension  of  the  abdominal  wall  as  possible.  With  slightly  curved  hands 
we  seize  the  two  poles  of  the  fetal  ovoid  and  try  to  press  the  breech 
up  and  the  head  down  over  the  pelvic  brim.  If  this  does  not  prove 
possible,  we  reverse  the  direction  of  the  movements,  and  endeavor 
to  push  the  head  up  to  the  diaphragm  and  the  breech  down  to  the 
entrance  of  the  pelvis. 


VERSION.  619 

When  thus  the  foetus  is  placed  longitudinally,  we  must  strive  to 
keep  it  in  its  new  position,  which  often  is  more  difficult  than  to  bring 
it  there.  The  woman  must  stay  in  bed  and  lie  on  her  back.  Two 
towels  are  tightly  rolled  into  hard  cylinders  and  applied  to  each  side 
of  her  abdomen,  where  they  are  kept  in  place  by  a  binder  pinned 
tightly  in  front.  If  the  woman  is  in  labor,  the  new  position  may  be 
secured  by  rupturing  the  membranes. 

During  pregnancy  a  similar  result  has  been  obtained  by  a  chiefly 
postural  treatment.  For  this  purpose  the  woman  is  placed  on  that 
side  where  the  lowest  pole  of  the  fetal  ovoid  is,  be  it  head  or  breech, 
and  friction  is  exercised  on  the  opposite  pole  in  ascending  direction. 

§  2.  Version  by  the  Internal  Digital  Method. — While  the  exter- 
nal version  has  its  time  when  the  cervix  is  closed  and  the  membranes 
unruptured,  or  at  least  so  recently  ruptured  that  most  of  the  liquor 
amnii  remains  in  the  ovum,  if  a  single  finger  can  pass  the  cervical 
canal  we  enter  on  the  domain  of  the  internal  digital  method.  This 
method  is  commonly  known  as  Braxton  Hicks' s  method^  so  called  in 
honor  of  its  inventor,  the  late  London  obstetrician  of  that  name,  or  as 
the  bipolar  method  or  the  combined  internal  and  external  method.  The 
two  last  denominations  are,  however,  objectionable  as  misleading. 
In  all  methods  we  act  on  the  two  poles  of  the  fetal  ovoid,  and  in 
the  so-called  internal  method  we  use  the  outside  hand  in  performing 
the  operation. 

Braxton  Hicks's  method,  like  that  by  external  manipulation,  can 
be  used  only  when  the  membranes  are  unruptured  or  recently  rup- 
tured, so  that  the  foetus  is  easily  movable.  It  may  be  employed  both 
for  cephalic  and  podalic  version. 

Modus  Operandi. — If  the  object  is  to  perform  cephalic  version,  the 
patient  is  placed  on  the  left  side,  with  the  head  bent  well  down  and 
the  knees  drawn  up.  For  the  introduction  of  the  hand  the  lubricity 
afforded  by  creolin  or  lysol  is  hardly  sufficient.  The  accoucheur 
should  smear  the  dorsal  surface  of  his  hand  with  a  stronger  lubricant, 
such  as  sterilized  olive  oil,  albolene,  lubrichondrin,  or  white  vaseline, 
in  soft  metal  tubes.  To  use  oil,  lard,  butter,  and  similar  greasy  sub- 
stances as  found  in  the  houses  or  vaseline  kept  in  a  glass  or  a  galipot 
is  objectionable  on  account  of  the  danger  of  infection.  Next,  the 
accoucheur  spreads  the  vulva  wide  open  with  the  fingers  of  his  right 
hand  and  bends  the  left  hand  so  as  to  form  a  cone,  which  he  intro- 
duces into  the  vagina.  Sometimes  it  is  not  even  necessary  to  intro- 
duce the  whole  hand,  three  or  four  fingers  being  found  sufficient,  so 
that  the  thumb  and  the  little  finger  may  remain  outside.  The  index- 
finger  and,  if  there  is  room  enough,  the  middle  finger,  too,  enter 
through  the  os  and  push  the  presenting  shoulder  in  the  direction  of 
the  breech.     At  the  same  time  pressure  is  exercised  from  without 


620 


OBSTETRIC    OPERATIONS. 


with  the  other  hand  on  the  head,  which  then  ghdes  down  over  the 
OS  (Fig.  445). 

In  placing  the  head  over  the  brim  care  should  be  taken  to  rectify 
any  tendency  to  face  presentation.  It  is  well,  if  the  breech  will  not 
rise  to  the  fundus  readily  after  the  head  is  fairly  in  the  os,  to  with- 
draw the  hand  from  the  vagina  and  with  it  press  up  the  breech  from 
the  exterior.  The  hand  which  is  retaining  the  head  from  the  outside 
should  continue  there  for  some  little  time  till  the  pains  have  insured 

Fig.  445. 


Cephalic  version  by  Braxtxjn  Hicks's  method. 


the  retention  of  the  foetus  in  its  new  position  and  the  adaptation  of  the 
uterine  walls  to  its  new  form.  Should  the  membranes  be  perfect,  it 
is  advisable  to  rupture  them  as  soon  as  the  head  is  at  the  os  uteri. 

For  podalic  version  the  procedure  is  somewhat  more  complicated. 
The  best  way  is  to  place  the  patient  on  her  back  with  bent  knees,  as 
this  gives  the  freest  play  to  both  the  accoucheur's  hands.  Next,  we 
introduce  that  hand  the  volar  surface  of  which  corresponds  to — that 
is,  will  most  easily  come  in  contact  with — the  abdominal  surface  of 
the  foetus.     Thus,  if  in  a  head  presentation  the  back  of  the  foetus  is 


VERSION. 


621 


turned  to  the  left  (first  and  fourth  positions),  the  left  hand  is  used, 
and  if  it  is  turned  to  the  right  (second  and  third  positions),  the  right 
hand  is  chosen.  Supposing  we  have  a  left  occipito-anterior  position 
of  a  vertex  presentation.  The  first  step  is  to  push  the  head  away 
from  the  brim  into  the  left  iliac  fossa  (Fig.  446)  with  the  fingers  of  the 
left  hand,  while  the  right  hand  from  without  presses  the  breech  in  the 
opposite  direction.  The  head  slides  out  of  reach,  and  the  shoulder 
arrives  at  the  os  and  lies  over  the  tips  of  the  fingers.     This  is  also 

Fig.  446. 


First  step  in  digital  podalic  version  in  head  presentation.    Elevation  of  the  head  and  depression 

of  the  breech. 


pushed  aside  by  the  internal  fingers  in  the  same  direction  as  the  head, 
downward  pressure  being  kept  up  on  the  breech  (Fig.  447)  until  a 
knee  comes  within  reach  of  the  fingers,  when  the  membranes,  if  still 
unruptured,  are  broken,  and  the  knee  is  seized  and  pulled  down 
through  the  os  (Fig.  448),  while  the  outer  hand  is  shifted  over  on  the 
head,  which  it  pushes  up  from  the  iliac  fossa. 

Occasionally  instead  of  a  knee  a  foot  comes  immediately  over  the 
OS,  when  it  is  seized  and  pulled  down  (Fig.  449).  While  the  leg  is 
being  pulled  down  in  the  axis  of  the  pelvis,  the  fa-tus  by  nature's  own 
efforts  rotates  so  that  its  back  turns  forward  (Fig.  450). 

The  method  of  Braxton  Hicks  is  of  particular  value  in  cases  of 


622 


OBSTETRIC    OPERATIONS. 


hemorrhage  due  to  placenta  preevia  (p.  496),  the  condition  for  which 
it  was  invented.     It  offers  the  immense  advantage,  that  if  the  cervix 


Fig.  447. 


Second  step  in  digital  podalie  version.    Elevation  of  shoulder ;  depression  of  breech. 

is  not  dilated  or  dilatable  enough  to  let  the  hand  pass,  we  may  still 
be  able  to  turn  the  foetus,  and  with  two  fingers — or,  if  we  can  hook 
it  into  the  popliteal  cavity  of  the  presenting  knee,  even  with  one 
finger — pull  down  a  leg.     The  leg  and  a  buttock  serve  as  a  tampon 

Fig.  448. 


Third  step  in  digital  podalie  version.    Seizure  of  a  knee  and  elevation  of  the  head. 

by  compressing  the  bleeding  site  in  the  lower  uterine  segment  from 
which  the  placenta  has  been  detached,  and  extraction  should  there- 


VERSION. 


623 


fore  not  be  made  until  the  cervix  is  fully  dilated,  when,  if  needed, 
other  means  of  arresting  hemorrhage  may  be  used. 

Another  reason  for  thus  postponing  delivery  is  to  avoid  the  dan- 
gerous lacerations  of  the  undilated  cervix. 

The  internal  digital  method  may  also  be  used  in  cases  in  which 
the  OS  is  well  dilated,  if  the  membranes  are  intact  or  recently  rup- 
tured ;  in  other  words,  when  the  foetus  is  freely  movable  ;  and  in 
former  times  it  was  a  great  point  that  the  uterus  was  hardly  entered. 
But  with  our  present  means  of  disinfection  this  feature  has  lost  much 

Fig.  449. 


Fourth  step  in  digital  podalic  version.    Drawing  the  leg  down  and  pushing  the  head  up. 


of  its  importance,  and,  the  method  being  more  complicated  and  slower 
than  the  internal  manual  version,  it  will  hardly  be  used  when  the 
latter  is  available. 

§  3.  Version  by  the  Internal  Manual  Method, — This  method 
practically  dates  from  the  French  surgeon  Ambroise  Pare  (1550).  In 
this  method  the  whole  hand  and  often  part  of  the  forearm  are  intro- 
duced into  the  uterus.  It  presupposes,  therefore,  that  the  os  is  di- 
lated or  dilatable  enough  to  let  the  hand  pass.  It  may  be  used  for 
cephalic,  pelvic,  or  podalic  version.  The  other  hand  is  always  used 
in  cooperation  with  the  internal  hand.  The  hand  that  is  to  be  intro- 
duced into  the  uterus  is  anointed  on  its  dorsal  surface,  and  so  is  the 
lower  half  of  the  forearm.  Other  details  differ  in  different  kinds  of 
version,  and  will  be  considered  in  connection  with  them. 


624 


OBSTETRIC    OPERATIOXS. 


§  4.  Cephalic  Version. — Since  it  is  normal  for  the  child  to  be 
born  head  first,  and  since  it  is  much  safer  for  it  to  come  into  the 
■world  in  this  way,  it  would  seem  natural  also  in  the  operation  of 
turning  to  favor  this  arrangement.  Still,  there  are  so  many  limita- 
tions to  its  practicability  that  it  is  not  used  much. 

Cephalic  version  is  indicated  in  transverse  presentations  if  the  head 
lies  lower  than  the  breech. 

Conditions. — First.  The  membranes  must  be  unruptured,  or  re- 
cently ruptured,  so  that  the  fcetus  is   rather  freely  movable.     If  the 

Fig.  450. 


Completed  digital  version. 


waters  have  drained  off,  and  the  uterus  has  contracted  around  the 
foetus,  this  kind  of  version  is  contraindicated. 

Second.  There  must  be  good  labor-pains.  In  twin  labors  it  hap- 
pens often  that  uterine  contractions  become  Aveak  after  the  birth  of 
the  first  child,  and  then  podalic  version  is  to  be  preferred. 

Third.  The  pelvis  must  not  be  contracted,  or  at  least  only  very 
little.     With  the  higher  degrees  podalic  version  is  to  be  preferred. 

Fourth.  There  must  be  no  dangers  threatening  mother  or  child, 
for  with  cephalic  version  we  cannot  at  any  moment  finish  labor,  as  we 
can  with  podalic  version. 


VERSION. 


625 


Methods. — First.  Postural  Treatment. — If  the  membranes  are  un- 
ruptured and  the  head  has  only  deviated  a  httle  to  one  side,  it  may  be 
brought  over  the  superior  strait  of  the  pelvis  by  simply  placing  the 
woman  on  that  side,  the  effect  of  which  is  to  make  the  fundus  uteri 
with  the  pelvic  end  of  the  foetus  by  gravity  tip  down  on  this  side,  and 
consequently  to  move  the  lower  uterine  segment  and  the  cervix  in  the 
opposite  direction. 

The  effect  of  this  position  may  still  be  enhanced  by  placing  a  bol- 
ster under  the  patient  in  such  a  way  that  it  exerts  direct  pressure  on 
the  deviated  head. 

Second.  Cephalic  version  may,  as  we  have  seen  above,  be  accom- 
plished by  the  external  method. 

Third.  We  have  seen  that  it  can  be  done  according  to  the  internal 
digital  method. 

Fourth.  It  may  be  obtained  by  different  varieties  of  the  internal 
manual  method, — Busch's  and  D'Outrepont's  methods. 

(a)  Busch''s  Method  (Fig.  451). — The  patient  is  placed  on  her  back. 
The  accoucheur  chooses  the  hand  heteronymous  to  the  position  of  the 

Fig.  451. 


Cephalic  version  by  Busch's  method. 


head — the  right  hand  when  the  head  lies  in  the  left  side,  and  the  left 
hand  when  it  lies  in  the  right  side.  With  this  hand  he  enters  the  uterus, 
ruptures  the  membranes,  seizes  the  head  and  draws  it  over  the  os. 

(6)  JD'Outreponfs  Method  (Fig,  452). — In  this  method  the  attack  is 
directed  against  the  presenting  shoulder.     For  this   purpose  the  ac- 

40 


626 


OBSTETRIC    OPERATIONS. 


coucheur  introduces  the  hand  homonymous  to  that  side  in  which  the 
head  hes — the  left  hand  when  the  head  is  in  the  left  side,  the  right 
when  it  is  in  the  right  side.  He  seizes  the  shoulder  between  his 
thumb  and  fingers,  lifts  it  and  pushes  it  over  in  the  direction  of  the 
breech.  Simultaneously  the  other  hand  from  without  pushes  the 
head  from  the  iliac  fossa  to  the  brim  of  the  pelvis. 

This  method  can  even  be  used  when  the  foetus  has  less  mobility 
than  that  required  for  external  version  or  Busch's  method. 

When  the  cephalic  version  has  been  accomplished,  in  whatever 
way  it  may  be,  the  permanence  of  the  obtained  results  should  be  se- 
cured. The  head  should  be  held  over  the  brim  until  uterine  con- 
tractions, aided  by  our  own  pressure  on  the  head,  engage  this  in  the 

pelvic  entrance. 

Fig.  452. 


Cephalic  version  by  D'Outrepont's  method. 

If  the  membranes  are  unbroken  and  the  os  is  dilated,  the  bag  of 
waters  should  be  ruptured,  but  in  so  doing  the  fetal  head  should  be 
pressed  well  down,  in  order  to  prevent  the  umbilical  cord  from  pro- 
lapsing. If  this  accident  happened  and  the  os  were  not  dilated,  the 
life  of  the  foetus  might  be  jeopardized.  Before  the  membranes  are 
ruptured  pressure  on  the  head  has  not  much  effect  in  engaging  it  in 
the  superior  strait,  but  after  the  waters  have  broken  we  can  mate- 
rially aid  nature  by  this  means. 

§  5.  Pelvic  Version. — Pelvic  version  consists  in  turning  the  foetus 
in  such  a  way  as  to  bring  the  breech  over  the  entrance  to  the  pelvis. 
It  is  not  much  used.  In  fact,  it  is  only  resorted  to  because  under 
given  circumstances  we  cannot  do  better.  Thus,  it  is  indicated  in 
transverse  presentation  if  the  os  is  not  much  dilated,  the  breech  is 


VERSION.  627 

lowest,  and  it  is  not  possible  to  bring  the  head  down.     In  this  case 
the  external  method  is  used. 

Pelvic  version  may  also  be  performed  if  in  internal  version  it  is  im- 
possible to  reach  the  foot  or  the  knee.  Then  it  may  perhaps  still  be 
possible  to  draw  the  breech  over  the  pelvic  brim  by  hooking  the  index- 
finger  over  the  groin  of  the  foetus  or  by  inserting  it  into  the  rectum. 

§  6.  Podalic  "Version. — In  this  kind  of  version  a  transverse  or 
head  presentation  is  changed  into  a  footling  presentation.  We  have 
seen  above  that  under  favorable  circumstances  this  can  be  done  by 
the  internal  digital  method.  But  much  more  frequently  podaHc  ver- 
sion is  performed  by  means  of  the  internal  manual  method,  which 
presently  will  be  described. 

Indications. — Podalic  version  is  indicated  under  the  following  cir- 
cumstances : 

First.  When  a  change  of  presentation  is  absolutely  necessary  for 
the  accomplishment  of  delivery, — namely,  in  transverse  presentation 
after  the  end  of  the  first  six  calendar  months  of  pregnancy.  Before 
that  time  the  fcetus  is  small  and  soft  enough  to  be  expelled  by  spon- 
taneous evolution  (p.  394).  Even  after  that  period  we  may  excep- 
tionally leave  the  case  to  nature, — namely,  when  the  fcetus  is  dead,  the 
pelvis  large,  and  gestation  not  far  advanced.  But  the  rule  is,  with 
transverse  presentation  during  the  last  three  months  of  gestation,  to 
turn,  and,  except  in  the  special  cases  mentioned  above,  to  use  podalic 
version  by  the  internal  manual  method. 

Second.  Podahc  version  is  indicated  also  in  head  presentation 
when  there  is  reason  to  believe  that  the  chances  for  a  safe  delivery 
will  be  bettered  by  changing  the  head  presentation  into  a  foot  pre- 
sentation. Thus,  podalic  version  may  be  indicated  in  cases  of  face 
presentation  (p.  374),  brow  presentation  (p.  375),  compound  pre- 
sentation (p.  396),  hydrocephalus  (p.  400),  anencephalus  (p.  403),  in 
delivering  the  second  twin  (p.  407),  double  monstrosities  (p.  408),  in 
contracted  pelves  with  a  conjugate  between  2|  and  8^  inches — from 
7  to  9  centimetres — (p.  463),  asymmetric  pelves  (p.  474),  uterine 
fibroids  (p.  431),  and  rarely  after  craniotomy. 

Third.  Podalic  version  may  be  indicated  by  dangers  threatening 
the  mother  or  foetus  and  demanding  a  prompt  termination  of  labor. 
Such  circumstances  are,  for  the  mother,  hemorrhage,  syncope,  dysp- 
noea, rupture  of  the  uterus,  eclampsia,  strangulated  hernia,  impending 
death ;  for  the  child,  hemorrhage,  asphyxia,  prolapse  of  the  pulsating 
umbilical  cord  in  face  presentation  in  every  case,  and  prolapse  of  the 
cord  with  vertex  presentation  if  it  cannot  be  replaced  and  retained. 

Fourth.  Inertia  ideri  rarely  calls  for  podalic  version,  except  in 
regard  to  the  delivery  of  the  second  twin. 

Extraction. — In  the  case  of  dangers  to  mother  or  foetus  and  of 


628  OBSTETRIC   OPERATIONS. 

inertia  uteri,  the  podalic  version  should,  of  course,  be  followed  imme- 
diately by  the  extraction  of  the  child  (p.  382).  Under  the  other 
indications  —  transverse  presentation  and  head  presentation  —  the 
operation  proper  of  podalic  version  is  accomplished  when  the  breech 
is  at  the  brim  of  the  pelvis.  In  this  connection  it  must  be  noticed 
that  it  is  not  enough  that  a  foot  is  brought  outside  the  vulva.  In 
order  to  be  sure  to  have  the  breech  engaged,  the  knee  must  be  at  the 
rima  pudendi. 

When  the  breech  is  engaged  the  expulsion  might  be  left  to  nature, 
but,  as  a  rule,  the  obstetrician  prefers  to  let  extraction  follow  imme- 
diately and  have  done  with  the  case,  so  much  more  so  as  the  condi- 
tion for  which  the  version  is  undertaken,  especially  contraction  of  the 
pelvis,  exposes  the  foetus  to  danger  and  calls  for  his  interference  also 
during  its  expulsion.  Only  in  placenta  prasvia,  when  the  foetus  is 
used  as  a  tampon,  the  immediate  extraction  is  contraindicated. 

Conditions. — First.  The  chief  condition  requisite  for  the  perform- 
ance of  podalic  version  is  that  the  pelvic  cavity  must  be  roomy  enough 
to  allow  the  passage  of  the  hand  of  the  accoucheur,  holding  one  or 
both  feet  of  the  foetus. 

Second.  The  presenting  part  must  not  be  so  impacted  in  the  pel- 
vis that  it  cannot  be  lifted  up  and  make  room  for  the  entering  hand 
and  arm. 

Third.  The  os  must  be  dilated  or  dilatable.  If  there  is  time,  it  is 
best  to  await  full  dilatation ;  but  if  the  indication  for  the  operation  is 
of  such  a  nature  that  immediate  delivery  is  urgently  called  for,  the 
obstetrician  will  perform  it  as  soon  as  he  can,  even  if  the  os  is  imper- 
fectly dilated. 

Fourth.  The  lower  uterine  segment  must  not  have  become  so  dis- 
tended that  by  the  additional  tension  caused  by  the  introduction  of 
the  hand  it  must  rupture.  When  the  contraction  ring  is  drawn  so' 
high  up  over  the  foetus,  turning  is  contraindicated. 

It  is  a  great  advantage  if  we  can  turn  before  the  membranes  are 
ruptured,  or  at  least  while  some  of  the  liquor  amnii  is  still  retained 
in  the  uterus.  But  even  if  all  the  waters  have  drained  off  and  the 
uterus  has  contracted  on  the  foetus,  podalic  version  by  the  internal 
manual  method  may  be  tried,  and  will  sometimes  succeed  while  the 
external  method  and  the  internal  digital  method  are  powerless  and 
cephalic  and  pelvic  version  are  out  of  the  question. 

Modus  Operandi. — The  operation  can  often  be  performed  in  the 
patient's  bed. 

Postwe. — She  may  be  placed  on  her  back  across  the  bed  as  for 
forceps  delivery  (p.  590),  or  she  may  be  placed  on  her  side.  The 
lateral  position  offers  in  most  cases  real  advantages  in  turning.  In 
easy  cases  one  position  is  as  good  as  the  other,  but  in  difficult  cases, 


VERSION.  629 

especially  when  the  abdomen  of  the  foetus  is  turned  forward  against 
the  abdominal  wall  of  the  mother,  it  is  easier  to  reach  the  feet  when 
the  patient  lies  on  her  side.  The  position  of  the  accoucheur's  arm  is 
much  more  natural  with  the  patient  on  her  side,  when  it  enters  in  a 
horizontal  direction  or  even  from  above  downward,  than  when  he  is 
obliged  to  force  it  from  below  upward. 

In  cross  presentations  the  patient  should  be  placed  on  that  side 
where  the  breech  is. 

Time. — If  the  membranes  are  entire  there  is,  as  a  rule,  no  hurry, 
and  the  accoucheur  can  and  should  wait  till  the  os  is  fully  dilated,  or 
he  should  dilate  it  by  the  means  described  above  (p.  583  etseq.).  But 
if  the  waters  have  broken  he  should  operate  promptly,  in  order  to 
save  as  much  liquor  amnii  as  possible  and  prevent  the  uterus  from 
closing  in  on  the  foetus. 

Anaesthesia. — The  patient  should  be  anaesthetized,  not  only  in  order 
to  save  her  from  pain,  but  also  because  full  anaesthesia  to  the  surgical 
degree  considerably  facilitates  the  execution  of  the  operation. 

Two  fillets  should  be  kept  within  reach.  They  should  be  about  a 
yard  long.  Linen  tape  half  an  inch  wide  or  narrow  lamp-wick  may 
be  used  when  properly  disinfected.  Means  for  reviving  the  child  in 
case  of  asphyxia  should  also  be  prepared  (p.  559). 

The  choice  of  the  hand  is  not  very  important,  the  best  proof  of 
which  is  that  the  rules  given  by  different  authors  differ  materially 
from  one  another.  The  choice  depends  also  on  the  position — dorsal 
or  lateral — in  which  we  place  the  patient.  The  guiding  principle 
should  be  to  introduce  that  hand  which  most  easily  will  reach  with 
its  volar  surface  the  abdomen  of  the  child.  In  head  presentations  we 
choose  the  left  hand  when  the  occiput  is  turned  to  the  left  (Fig.  453), 
and  the  right  when  it  is  turned  to  the  right.  In  transverse  presenta- 
tion the  writer  would  recommend  to  place  the  woman  on  the  side 
where  the  breech  is  and  introduce  the  homonymous  hand  if  the  back 
of  the  foetus  turns  forward,  which  it  commonly  does,  and  the  hete- 
ronymous hand  in  dorsoposterior  positions.  If  the  breech  is  in  the 
left  side  the  woman  should  lie  on  the  left  side,  and  if  the  ftptus  is 
in  dorso-anterior  position  the  accoucheur  introduces  the  left  hand, 
but  if  the  back  of  the  foetus  is  turned  backward — which  is  rarer — 
the  right  hand  is  preferable.  If  the  breech  lies  to  the  right  the 
woman  is  placed  on  her  right  side,  and  the  accoucheur  uses  the  right 
hand  if  the  back  is  turned  forward,  and  the  left  hand  if  the  back  is 
turned  backward. 

In  difficult  turnings  the  hand  often  becomes  so  numb  from  press- 
ure of  the  contracting  uterus  that  it  can  not  be  used  any  longer.  To 
some  extent  this  may  be  avoided  by  holding  the  hand  flat  against  the 
foetus  during  a  labor-pain ;  but  when  it  happens,  the  hand  must  be 


630 


OBSTETRIC    OPERATIONS. 


withdrawn  and  replaced  by  the  other ;  and  sometimes  this  change  has 
to  be  repeated  several  times. 

It  appears  from  the  foregoing  that  the  accoucheur  should  use  his 
utmost  care  in  making  out  the  presentation  and  position  of  the  foetus, 
in  order  to  obtain  the  greatest  advantage  in  turning  it.  But  if  it  is  not 
possible  for  him  to  arrive  at  a  definite  conclusion  in  this  respect,  he 
had  better  introduce  the  left  hand,  because  in  head  presentations  the 
back  is  most  commonly  turned  to  the  left.    In  this  and  in  other  cases, 


Fig.  453. 


Podalic  version  by  the  internal  manual  method,  head  presentation. 

if  the  hand  chosen  does  not  adapt  itself  well  to  the  situation  found 
in  the  uterus,  it  should  be  withdrawn  and  replaced  by  the  other. 

If,  in  neglected  shoulder  presentation,  the  arm  prolapses,  a  fiUet 
should  be  placed  at  the  wrist,  so  as  to  be  able  to  retain  it,  and  the 
homonymous  hand  should  be  introduced  (Fig.  454).  How  it  is  found 
out  which  is  the  homonymous  hand  has  been  explained  above  (p. 
393). 

When  the  patient  is  in  the  dorsal  posture,  the  accoucheur  stands 
in  front  of  her,  between  her  separated  legs.  If  she  hes  on  the  side, 
he  stands  behind  her. 


VERSION. 


631 


The  hand  is  lubricated  and  introduced  as  described  above  (p. 
619).  The  other  hand  is  placed  on  the  abdomen  of  the  patient,  and 
co-operates  with  that  in  the  uterus,  sometimes  pushing,  sometimes 
pulling  on  the  part  to  be  dislodged.  The  hand  should  be  introduced 
during  the  interval  betw^een  contractions. 

If  the  membranes  have  ruptured,  the  accoucheur  enters  the 
interior  of  the  ovum.  If  they  are  intact,  he  ruptures  them  then  and 
there,  pushing  the  arm  rapidly  in  so  as  to  prevent  the  waters  from 
escaping.  If  the  position  of  the  feet  is  known,  it  is  best  to  go  directly 
for  them.  Otherwise  the  hand  follows  the  side  of  the  foetus  until  it 
reaches  the  breech.  Then  it  descends  along  the  thigh  and  the  leg  to 
the  foot. 

Fio.  454. 


Podalic  version  with  prolapsed  arm. 

As  this  is  slippery,  a  good  hold  is  secured  by  seizing  it  between 
the  index  and  the  middle  fmger  above  the  ankle  and  pressing  the 
thumb  against  the  sole  (Fig.  455). 

Several  great  obstetricians  prefer  to  seize  the  knee,  for  which  there 
are  excellent  reasons.  As  a  rule  it  is  nearer.  Secondly,  you  need 
only  one  fmger  for  hooking  it  behind  the  knee.  Thirdly,  the  knee 
being  nearer  the  part  you  want  to  dislodge,  you  can  exert  greater 
force,  and  the  foetus  can  stand  more  at  the  knee  than  at  the  foot 
without  injury. 


632 


OBSTETRIC    OPERATIONS. 


It  is  better  only  to  pull  one  lower  extremity  down,  as  tlie  other^ 
extended  along  the  abdominal  surface,  serves  to  protect  the  umbilical 
cord.  If  both  are  seized  at  the  same  time,  which  may  be  done  when 
the  child  is  dead,  one  is  held  between  the  thumb  and  the  index-fmger 
and  the  other  between  the  index  and  the  middle  fmger. 

Fig.  455. 


Way  of  seizing  foot. 


Opinions  also  differ  much  as  to  which  knee  or  foot  should  be 
seized,  the  upper  or  the  lower.  Since  it  is  easier  to  seize  the  lower 
foot,  and  since  in  the  vast  majority  of  cases  turning  may  be  effected 
by  pulling  on  it,  it  is  the  simplest  to  take  the  first  foot  you  can  get 
hold  of.  If,  however,  this  foot  in  cross  presentation  is  that  of  the  same 
side  as  the  presenting  shoulder,  the  foetus  is  apt  to  become  jammed 
in  the  pelvis  (Fig.  456),  while  if  you  seize  the  opposite  knee  or  foot 
the  evolution  is  easily  effected  (Fig.  457). 

If  the  revolution  does  not  succeed  by  pulling  on  the  foot  first 
seized,  the  other  must  be  sought  and  brought  down.  For  safety's 
sake  a  fillet  is  placed  over  the  first  foot.  The  accoucheur  places 
the  volar  surface  of  the  corresponding  hand  against  its  inside  and 
follows  it  up  to  the  breech.  The  hand  is  next  carried  over  on  the 
other  thigh  and  follows  it  until  the  knee  is  reached.  Putting  the 
thumb  in  the  popliteal  fossa  and  a  couple  of  fingers  along  the  tibia, 
he  bends  it,  seizes  the  foot  and  pulls  it  down. 

In  an  asymmetric  pelvis  great  advantage  may  be  derived  by  pull- 
ing on  that  foot  which  will  cause  the  broader  occiput  to  come 
through  the  wider  part  of  the  pelvis  (p.  474). 

Difficulties. — If  the  waters  have  drained  off,  turning  may  prove 
very  difficult  or  even  impossible.     The  uterus  may  be  in  a  constant 


Fig.  45G. -Seizing-  the  leg  of  the  same  side  as  the  presenting  shoulder. 


'm 


-Sei/.ing  leg  opiKL^ile  t>.  tlie  piesenlmg  slioulder. 


VERSION. 


633 


condition  of  contraction  without  relaxation — so-called  tetanus  uteri. 
Here  chloroform  is  the  remedy,  but  it  must  be  administered  to  deep 
narcosis.  If  no  chloroform  were  obtainable,  large  doses  of  mor- 
phine and  a  warm  bath  might  be  useful. 

The  uterus  may  be  in  close  contact  with  the  foetus  and  still 
not  be  tetanically  contracted.  This  condition  of  mere  adaptation 
of  the  uterus  need  not  present  any  particular  hinderance  to  the 
introduction  of  the  hand. 

Fig.  459. 
Fig.  458. 


jraking  a  noose  with  one  hand,  first  step. 


Making  a  noose  with  one  hand,  second  step. 


Immediately  after  the  escape  of  the  liquor  amnii  the  uterus 
may  be  so  strongly  contracted  that  the  hand  cannot  enter.  Then 
it  is  better  to  wait  a  little  until  it  relaxes,  and  give  chloroform. 

If  the  feet  or  knees  cannot  be  reached,  it  is  sometimes  possible 
and  advantageous  to  turn  the  child  around  its  longitudinal  axis. 

It  may  be  quite  difficult  to  seize  a  foot  or  to  pull  it  down.  Here  the 
fillet  is  of  great  value.  The  practitioner  should  practise  the  formation 
of  a  noose  by  means  of  one  hand,  so  as  to  be  able  to  form  one  while 
one  of  his  hands  is  in  the  uterus.      The  ribbon  is  laid  over  the  back 


634 


OBSTETRIC    OPERATIONS. 


of  the  index  and  middle  fmger.  Next  the  wrist  is  bent  and  the  ends 
seized  between  these  fingers  and  drawn  through  the  loop  (Figs.  458, 
459).  The  noose  thus  formed  is  carried  around  the  thumb,  index, 
and  middle  finger  (Fig.  460),  and  with  them  pushed  over  the  foot  and 
tightened  above  the  ankles  by  pulling  on  the  free  ends  (Fig.  301,  p. 
387).  If  the  noose  cannot  be  applied  in  this  way,  it  may  be  pushed 
up  from  the  fingers  to  the  foot  with  a  long  artery-forceps  or  clamp. 

If  there  is  not  room  enough  for  the  three  fingers,  it  may,  perhaps, 
still  be  possible   to   snare  the   foot  by  means  of  Braun's  fillet-carrier 


Fig.  461. 


Fig.  460. 


Carrying  noose  on  fingers. 


Braun's  fillot-carrier. 


(Fig.  461).  It  consists  of  a  rod  about  a  foot  long,  with  a  hole  near 
each  end,  and  a  strong  thread,  which  is  carried  through  the  holes, 
forming  a  loop  at  the  upper  end,  through  which  the  tape  is  passed. 
The  rod  is  guided  with  the  hand  up  to  the  foot,  and  when  the  noose 
has  been  brought  around  the  ankle,  the  ligature  is  withdrawn  and 
the  rod  removed. 


VERSION.  635 

This  may  also  be  accomplished  by  means  of  a  sound-like  rod 
ending  in  a  little  curved  crutch  (Fig.  462),  an  instrument  used  in 
snaring  intra-uterine  polypi. 

Robert  Barnes  praises  a  wire  ecraseur  as  a  means  of  snaring  a 
foot.  In  order  not  to  injure  the  leg  the  wire  might  be  covered  with 
a  piece  of  rubber  tubing. 

Considerable  difficulty  may  also  be  experienced  in  trjang  to  effect 
the  revolution  of  the  foetus.  In  simpler  cases  this* is  obviated  by 
pulling  on  the  leg  in  the  direction  of  the  head.  Secondly,  pressure 
may  be  exercised  on  the  head  from  without,  so  as  to  lift  it  while  the 
breech  is  being  pulled  down.  Thirdly,  the  head  may  be  pushed 
away  with  the  thumb  of  the  internal  hand.  If  this  does  not  suffice, 
recourse  may  be  had  to  Justine  Siegemundin's  double  manoeuvre.  A 
fillet  is  passed  around  the  leg,  which  is  pulled  down  with  one  hand, 

Fig.  462. 


Routh's  fillet-carrier,  used  in  snaring  intra-uterine  polypi. 

while  the  other,  introduced  into  the  interior  of  the  uterus,  presses  the 
head  up  (Fig.  463). 

The  resistance  met  with  during  turning  may  be  due  to  crossing  of 
the  legs.     Then  the  other  foot  must  be  brought  down. 

The  prolapsed  arm  should  neither  be  replaced  nor  amputated,  but 
surrounded  by  a  fillet,  as  described  above. 

In  regard  to  extraction^  the  reader  is  referred  to  what  has  been 
said  about  it  in  treating  of  pelvic  presentation  (pp.  382-387) ;  but 
while  in  ordinary  cases  of  breech  presentation  we  warned  against 
pulling  on  the  legs  and  recommended  to  leave  the  expulsion  to  nature, 
after  version,  as  a  rule,  extraction  has  to  follow  promptly,  and  then  we 
pull  directly  with  the  fingers  or  by  means  of  a  fillet  on  the  foot  which 
we  have  brought  out.  Traction  should  always  be  applied  as  near 
outside  the  vulva  as  possible  in  order  not  to  injure  the  foetus.  As 
this  is  slippery,  we  surround  it  with  a  clean  towel.  In  pulling  we 
favor  rotation  in  such  a  direction  that  the  occiput  turns  forward. 
When  the  second  leg  has  been  delivered,  we  pull  on  both  thighs,  then 
on  the  pelvis,  and  finally  on  the  abdomen  and  back  until  the  lower 
angle  of  the  scapula  is  reached,  Avhen  the  arms  are  delivered  and  after 
them  the  head,  as  described  at  the  place  referred  to. 

Prognosis. — In  simple  cases  a  foetus  may  be  turned  and  extracted 
with  ease  and  expedition  without  harm  to  itself  or  its  mother.  This 
holds  good  particularly  when  there  is  no  mechanical  disproportion 
between  pelvis  and  foetus,  and  the  membranes  are  unruptured  or 
recently  ruptured  with  the  preservation  of  most  of  the  liquor  amnii. 


636 


OBSTETRIC   OPERATIONS. 


In  other  cases  version  may  be  fraught  with  dangers  for  mother 
and  foetus.  For  the  mother  we  must  consider  possible  infection, 
tears  of  the  cervix,  vagina,  and  perineum,  and  rupture  of  the  uterus. 
But  with  proper  precautions  the  prognosis  for  her  is,  upon  the  w^hole, 
favorable.  For  the  foetus  it  is  much  more  serious.  Any  circum- 
stance that  prevents  a  deliven-  within  a  few  minutes  may  cause  its 

Fig.  463. 


Double  manteuvTe  for  dislodging  head. 


death  (p.  380),  especially  through  compression  of  the  umbilical  cord 
or  detachment  of  the  placenta. 

Comparison  between  Forceps  Delivery  and  Version. — Version  and 
forceps  delivery  are  the  two  common  conservative  operations,  which 
in  modern  times  have  considerably  lessened  the  recourse  to  craniot- 
omy. Version  has  the  advantage  that  it  does  not  require  any  instru- 
ments, and  may  therefore  be  available  under  circumstances  where 
none  are  at  hand.  It  can  be  performed  when  the  conditions  we  have 
demanded  for  the  application  of  the  forceps — a  fully  dilated  os  and 
engagement  of  the  head — are  not  present. 

"When  the  head  is  freely  movable  over  the  brim  of   the  pelvis, 


SYMPHYSEOTOMY.  637 

version  is  the  operation  to  perform.     When  the  head  is  engaged,  for- 
ceps should  be  used.     In  general,  the  forceps  is  safer  for  the  child. 

In  contracted  pelves  with  a  true  conjugate  of  3J  inches  (8  centi- 
metres), some  obstetricians  prefer  early  version  and  extraction  to 
expectancy  and  the  application  of  the  forceps  (see  p.  465). 


CHAPTER   VIII. 
SYMPHYSEOTOMY. 


After  having  considered  the  more  common  conservative  obstet- 
ric operations,  forceps  delivery  and  version,  it  remains  to  describe  the 
rarer  operations  belonging  to  the  same  category,  symphyseotomy  and 
Csesarean  section,  which  differ  from  the  others  by  being  distinctly 
surgical  operations,  in  which  tissues  are  cut. 

Symphyseotomy^  is  an  operation  in  which  the  symphysis  pubis  is 
severed. 

It  is  a  comparatively  young  procedure,  having  been  proposed  by 
the  French  medical  student  Jean  Rene  Sigault  to  the  Academy  of 
Medicine  of  Paris  in  1768,  and  performed  for  the  first  time  by  the 
same  physician  in  1777.  At  that  time  Caesarean  section  was  almost 
sure  death,  and  the  new  operation,  being  supposed  to  be  destined  to 
supplant  it,  was  hailed  with  enthusiasm  in  France,  although  some  of 
the  leading  obstetricians  of  the  day  opposed  it  from  the  beginning.  It 
found  favor  in  Italy,  but  was  rejected  in  England  and  Germany,  a 
grouping  in  which  there  doubtless  was  a  religious  element  at  work, 
the  two  former  being  preponderatingly  Roman  Catholic  countries, 
while  in  the  two  latter  Protestantism  prevails.  The  Church  of  Rome 
has  from  olden  times  hurled  its  anathema  against  the  destruction  of 
fetal  life  under  any  circumstances,  and  it  saw  in  the  new  operation  a 
substitute  for  craniotomy. 

On  account  of  the  bad  results,  its  triumph  was,  however,  of  short 
duration  even  in  the  land  of  its  birth.  Italy  alone  held  out  and 
preserved  this  useful  operation  for  coming  generations.  Morisani  of 
Naples  brought  the  subject  before  the  International  Medical  Congress 
convened  at  London  in  1881,  but  it  hardly  received  any  attention  un- 
til 1891,  when  Spinelli,  a  pupil  of  Morisani,  during  a  visit  to  Paris, 
demonstrated  the  operation  to  Pinard,  and  the  Parisian  obstetrician 
Charpentier  simultaneously  heard  Morisani  lecture  on  it  at  Naples, 

'  Garrigues,  "Symphyseotomy,  with  the  Report  of  a  Successful  Case,"  Amer. 
Jour.  Med.  Sci.,  March-April,  1893;  "Symphyseotomy,"  Amer.  Jour.  Obst., 
1893,  vol.  xxviii..  No.  5;  "On  Symphyseotomy,  with  the  Report  of  a  New 
Case,"  Medical  Record,  Nov.  10,  1894,  vol.  xlvi.,  No.  19. 


638  OBSTETRIC    OPERATIONS. 

and  presented  a  report  on  it  to  tlie  Academy  of  Medicine  of  Paris, 
After  having  tried  it  in  practice,  Pinard  became  an  enthusiastic  cham- 
pion for  the  operation  in  1892  and  has  remained  so  ever  since. 
Obstetricians  in  other  countries  followed  his  example,  and  obstetrical 
societies  declared  themselves  in  favor  of  its  adoption  among  the 
legitimate  resources  of  the  obstetrician. 

Personally  I  performed  the  first  symphyseotomy  in  New  York  on 
December  30th,  of  the  same  year. 

Space  Gained. — The  object  of  the  operation  is  to  obtain  a  tem- 
porary enlargement  of  the  pelvis,  which  goal  both  experiments  on  the 
cadaver  and  clinical  experience  have  shown  can  be  reached.  In  order 
to  be  conclusive,  these  post-mortem  experiments  must,  however,  be 
made  on  bodies  of  women  who  died  at  or  near  term  or  a  short  time 
after  delivery,  for  during  pregnancy  the  ligaments  that  form  the  hinges 
between  the  pelvic  bones  become  much  more  mobile  than  before  or 
later.  If  the  knees  and  hip-joints  are  kept  bent,  as  they  ought  to  be, 
and  the  symphysis  is  cut,  the  ends  of  the  bones  separate  spontane- 
ously from  3  to  4  centimetres  (1 J  to  1|  inches).  This  is  due  to  the 
elasticity  of  the  sacro-iliac  articulations,  the  contraction  of  the  muscles 
surrounding  the  pelvis,  especially  the  gluteus  maximus  muscle,  and 
the  weight  of  the  pelvis  in  front  of  the  sacro-iliac  joint  and  that  of  the 
lower  extremity.  By  pulling  on  the  iliac  bones  or  pressing  the  knees 
outward,  this  distance  may  easily  be  increased  to  7  centimetres  (2| 
inches).  And  the  same  distance  has  been  measured  during  extraction 
with  forceps,  without  any  injury  to  the  sacro-iliac  joints.  It  is  gener- 
ally stated  that  if  this  separation  is  carried  to  8,  9,  or  10  centimetres 
(3^  to  4  inches),  one  or  both  joints  crack  and  open  ;  but  that  there 
are  exceptions  to  this  rule  appears  from  my  second  symphyseotomy, 
in  which  the  separation  after  the  extraction  of  the  large  child  was  5 
inches  (13  centimetres),  without  injury  to  the  articulations. 

When  the  pubic  bones  separate,  the  anteroposterior  diameter  of 
the  pelvis  ceases  to  exist.  The  gap  in  front  allows  the  eminence  of 
the  anterior  parietal  bone  to  enter,  which  has  the  same  effect  as  if  the 
diameter  became  6-8  millimetres  (:^-f  inch)  longer.  Besides,  the  dis- 
tance from  the  centre  of  the  promontory  to  the  end  of  the  pubic  bones 
increases  the  more  the  greater  the  distance  becomes  between  these 
bones.  It  has  been  found  that  this  increase  is  about  2  millimetres  for 
each  centimetre  distance  between  the  pubic  bones.  The  maximum 
safe  distance  of  7  centimetres  (2|  inches)  gives  consequently  an  elon- 
gation of  14  millimetres  (i.e.,  over  J  inch).  Added  to  the  6  or  8  mil- 
limetres gained  by  the  protrusion  of  the  parietal  eminence  between 
the  ends  of  the  severed  pubic  bones,  that  makes  the  total  gain,  so  far 
as  the  anteroposterior  diameter  of  the  pelvis  is  concerned,  20  or  22 
millimetres  (nearly  an  inch).     But  not  this  alone  ;  the  transverse  and 


SYMPHYSEOTOMY.  639 

oblique  diameter,  and  every  line  drawn  from  the  middle  of  the  prom- 
ontory to  a  point  on  the  anterior  half  of  the  iliopectineal  line,  in- 
creases from  one-quarter  to  one-half  of  the  distance  between  the  ends 
of  the  bones,  so  that  at  the  safe  distance  of  7  centimetres  the  increase 
will  be  from  17  to  35  millimetres  (f- IJ  inches),  A  pelvis  which 
before  being  cut  only  admitted  a  circle  of  6  centimetres  diameter,  after 
the  separation  admits  one  of  8.4  centimetres;  and  one  which  before 
the  operation  only  admitted  one  of  8  centimetres,  after  the  operation 
admits  one  of  9.8  centimetres.  Besides  the  gain  in  space  obtained 
on  the  same  level,  the  ends  of  the  broken  ring  can  be  moved  up  and 
down  perpendicularly,  which  may  offer  an  additional  help  in  the 
delivery  of  the  child. 

Prognosis. — In  many  cases  more  or  less  severe  hemorrhage  has 
occurred.  Even  deaths  from  this  cause  have  been  reported,^  and  sev- 
eral times  hemorrhage  could  only  be  checked  by  circumventing  the 
crura  of  the  clitoris.  Hemorrhage  may  be  arterial  or  venous.  As 
a  rule,  no  large  arteries  are  met  with,  but  one  operator  in  a  fatal 
case  met  with  one  running  in  the  direction  of  the  descending  ramus  of 
the  pubis,  which  was  as  large  as  the  radial.^  Behind  and  below  the 
symphysis  run  large  veins,  which  have  been  cut  in  many  operations. 
Exceptionally,  a  secondary  hemorrhage  has  arisen.^  Numerous  injuries 
to  the  mother  have  occurred.  The  vestibule  and  vagina  have  been 
torn.  The  bladder  has  been  caught  between  the  ends  of  the  bones 
in  bringing  them  together  after  the  operation,  or  wounded  by  the 
sharp  edges  of  the  bones  during  the  extraction  of  the  foetus.  Re- 
peatedly the  operation  has  left  a  vesicovaginal  fistula.  A  temporary 
incontinence  due  to  pressure  of  the  urethra  is  quite  common,  and 
several  times  this  canal  has  been  wounded  during  the  operation  or 
has  subsequently  given  way  to  suppuration  in  the  surroundings.  In 
one  case  the  whole  upper  wall  was  torn,  and  although  the  edges  were 
united,  the  incontinence  remained  permanently.^  Sometimes  the  in- 
juries have  healed  spontaneously,  and  in  most  cases  the  wounds  have 
been  successfully  united  by  suture.  Not  rarely  one  or  both  sacro- 
iliac articulations  have  been  ruptured,  and  given  rise  to  a  permanently 
waddling  gait,  which,  however,  does  not  prevent  the  patient  from 
walking  miles  and  doing  the  hardest  physical  work.  Post-partum 
hemorrhage  is  common,  probably  on  account  of  the  administration 
of  chloroform  and  the  rapid  evacuation  of  the  uterus.  Fever  is  also 
quite  frequent. 

The  foetus  suffers  less  injury.  Still  cases  of  fracture  of  the  cra- 
nium have  been  reported.  The  prognosis  for  the  fcetus  is  better  with 
delivery  by  forceps  than  with  version.  If  the  fa;tus  is  not  much 
exposed  to  injury,  it  runs  other  risks ;  especially  is  it  quite  common 

^  The  bibliographic  references  are  found  at  the  end  of  the  chapter,  p.  656. 


640  OBSTETRIC    OPERATIONS. 

that  children  delivered  by  symphyseotomy  are  born  asphyxiated. 
This  asphyxia  may  be  attributed  to  the  slowness  of  labor  before  the 
operation,  premature  rupture  of  the  membranes,  prolapse  of  the  cord, 
or  the  manual  or  instrumental  extraction  of  the  child. 

As  to  the  hemorrhage  and  injuries  that  have  happened  to  the 
mother,  they  can  probably  be  entirely  avoided  by  a  mode  of  operating 
which  presently  will  be  described. 

On  account  of  the  many  injuries  followed  by  suppuration,  conva- 
lescence has  been  protracted.  Thus,  in  the  clinic  of  Leipsic  the  aver- 
age time  has  been  thirteen  weeks.^ 

Mortality  has  also  been  considerable.  Rubinroth,''  examining  the 
world's  literature  for  the  three  years,  1896, 1897,  and  1898,  found  136 
cases  with  a  maternal  mortality  of  11  per  cent.,  and  an  infantile  mor- 
tality of  14  per  cent.^  This  large  mortality,  however,  loses  much  of  its 
significance  by  examining  details.  Thus,  we  find  that  Pinard  had  12 
per  cent,  maternal  mortality,  but  he  had  the  same  mortality,  due  to 
sepsis,  with  craniotomy,^  where  there  ought  not  to  be  any  at  all,  which 
awakens  the  suspicion  that  asepsis  and  antisepsis  were  not  properly 
attended  to,  or  that  some  other  avoidable  error  in  the  treatment  pre- 
vailed. Zweifel  reported  31  consecutive  operations,  Kiistner  7,  and 
Bar  23,  without  a  death.'* 

Secondly,  it  must  be  remembered  that  a  large  number  of  sym- 
physeotomies have  been  performed  after  the  woman  had  been  long  in 
labor  and  treated  by  midwives  or  general  practitioners,  while  nobody 
would  be  willing  to  perform  Caesarean  section  under  similar  conditions. 

Other  obstetric  operations,  such  as  the  high  forceps  operation  and 
version  followed  by  extraction,  have  also  a  high  maternal  mortality. 

If  the  operation  is  held  within  proper  limits  and  properly  per- 
formed, and  especially  if  the  strictest  antisepsis  and  asepsis  have  been 
observed  from  the  moment  the  patient  was  taken  in  labor,  there  is  no 
danger  for  her  life  in  the  operation  itself. 

Indications  and  Limits. — Symphyseotomy  having  only  been  before 
the  profession  for  a  decade  since  its  revival  in  1892,  views  as  yet  differ 
much  among  leading  obstetricians  in  regard  to  the  field  it  should 
occupy  among  obstetric  operations.  Morisani  speaks  only  of  its  use 
in  the  flat  pelvis,  and  basing  an  argument  on  the  average  length  of  the 
biparietal  diameter  of  the  fetal  head,  95  millimetres  (3^  inches),  which 
by  compression  may  be  reduced  to  88  millimetres  (3^  inches),  and 
the  addition  gained  for  the  true  conjugate  by  symphyseotomy,  20-22 
millimetres  (|-|  inch),  he  concludes  that  the  lowest  limit  of  the  oper- 
ation is  67  millimetres  (2|  inches)  true  conjugate,  and  the  highest  88 
millimetres  (3^  inches).  With  a  true  conjugate  of  67  millimetres 
(2|  inches)  it  is  difficult ;  with  one  of  74  millimetres  (3  inches)  and 
upward  it  becomes  more  and  more  easy. 


SYMPHYSEOTOMY.  641 

But  such  mathematical  calculations  are  of  little  value  in  obstetrics, 
where  constantly  we  have  to  deal  with  unknown  or  little-known  factors. 
The  true  conjugate  cannot  be  measured,  but  is  found  by  a  calculation 
into  which  there  enters  much  uncertainty,  and  the  size  of  the  biparietal 
diameter  of  the  foetus  hidden  in  the  depth  of  its  mother's  abdomen 
is  still  less  reducible  to  measurements  expressed  in  the  terms  of  an 
accurate  standard. 

Practical  observation  has  taught  that  delivery  by  normal  birth, 
forceps  or  version  is  possible  down  to  a  true  conjugate  of  2|  inches 
(7  centimetres)  if  the  child  is  small  and  the  head  easily  moulded ; 
but  both  forceps  and  version  give,  in  general,  disastrous  results  with 
a  conjugate  below  3J  inches  (8  centimetres).  There  is  a  great  mor- 
tality, both  maternal  and  fetal,  and,  if  the  child  survives,  there  is 
danger  of  its  becoming  idiotic  or  epileptic.  The  safe  and  proper  field 
for  symp)hyseotomy  ivith  fiat  pelvis  lies,  therefore,  in  cases  where  the  conju- 
gate is  between  2|-  and  3^  inches  (7—9  centimetres). 

Pinard  ^^  has  introduced  the  following  rules  in  his  clmic  : 

1.  No  induction  of  premature  labor  to  be  done  if  symphyseotomy 
at  term  promises  to  allow  the  delivery  of  a  living  child. 

2.  No  craniotomy  to  be  performed  on  a  living  foetus. 

3.  In  any  case  of  bony  obstruction  to  the  passage  of  the  head, 
w^hich  is  not  overcome  by  uterine  contraction,  symphyseotomy, 
pubiotomy,  ischiopubiotomy,  or  coccygectomy  shall  be  performed,  if 
the  head  is  properly  placed,  and  if  sufficient  room  for  its  passage  will 
l)e  gained  by  the  operation. 

4.  In  cases  of  absolute  narrowness  of  the  pelvis,  utero-ovarian 
amputation  is  to  be  performed. 

He  has  abandoned  version  and  rarely  uses  the  forceps  in  the  cases 
covered  by  the  third  rule. 

Diametrically  opposed  to  Pinard,  Leopold"  has  little  use  for 
symphyseotomy,  and  prefers  craniotomy  and  Ctesarean  section. 

As  a  matter  of  fact,  symphyseotomy  has  been  performed  or 
recommended  for  (1)  flat  pelvis ;  (2)  pelvis  partly  obstructed  by  a 
tumor ;  (3)  narrowness  of  the  transverse  diameter  of  the  outlet ;  (4) 
kyphotic  pelvis  (p.  480) ;  (5)  occipitoposterior  position  of  the  present- 
ing vertex ;  (6)  lateral  obliquity  of  head  (ear  presentation,  p.  366) ; 

(7)  face  presentation  with  persistent  mentoposterior  position  (p.  371) ; 

(8)  brow  presentation  (p.  876) ;  (9)  large  foetus. 

In  the  writer's  opinion,  it  is  very  difficult  at  the  present  time  to 
give  general  rules  when  symphyseotomy  is  indicated,  but  he  is  inclined 
to  think  that  it  ought  to  be  performed  much  oftencr  than  it  is  in 
America.  Many  things  have  to  be  taken  into  consideration.  In  hos- 
pital practice  I  think  Pinard's  rules  might  be  followed,  if  for  no  other 
reason  in  order  to  perform  the  operation  often,  become  familiar  with 

41 


642  OBSTETRIC   OPERATIONS. 

it,  and  improve  its  technique.  The  obstetrician  in  charge  of  such 
an  important  institution  as  a  lying-in  hospital  owes  greater  allegiance 
to  science  than  to  anything  else.  It  behooves  him  to  collect  material, 
observe  it,  and  describe  it  so  well  that  his  experience  may  become  a 
guide  for  the  profession  at  large.  He  has  certainly  the  right  to  refuse 
to  kill  a  foetus,  and  even  to  expose  it  to  the  great  risks  of  induced  pre- 
mature labor,  when  he  can  offer  a  means  by  which  both  mother  and 
foetus  may  be  saved.  In  private  practice  the  case  is  different.  The 
accoucheur  is  here  engaged  to  see  a  woman  safely  through  her  con- 
finement. Those  Avho  have  secured  his  services  have  a  certain  right 
within  the  bounds  of  law  and  morality  to  see  their  wishes  accom- 
plished. Most  often  the  accoucheur  is  urged  to  save  the  mother  even 
at  the  expense  of  the  foetus  ;  but  maternal  heroism  or  inheritance  con- 
siderations sometimes  incline  the  balance  in  favor  of  the  latter.  Con- 
siderations of  necessity  and  expediency  also  impose  themselves.  The 
first  question  in  this  respect  will  be  whether  the  physician  is  able  to 
perform  the  operation,  or  other  more  skilful  help  can  be  procured, 
and  if  the  necessary  assistance  can  be  obtained.  For  a  symphyseot- 
omy at  least  two  skilled  persons — an  obstetrician  and  a  surgeon — are 
required.  After  symphyseotomy  there  is  a  protracted  convalescence, 
and  the  question  of  the  financial  resources  of  the  patient  must  often 
have  some  weight. 

In  consultation  practice  the  case  is  often  seen  so  late  that  the 
patient  is  exhausted  and  the  child  weakened ;  and  quite  commonly 
the  antiseptic  measures  taken  have  been  so  imperfect  that  there  is 
strong  suspicion  of  the  patient  having  been  infected. 

Under  all  circumstances  it  ought  to  be  borne  in  mind  that  sym- 
physeotomy is  a  serious  operation,  containing  elements  of  danger 
for  the  life  or  the  health  of  both  mother  and  foetus.  In  the  begin- 
ning an  expectant  treatment  is  indicated,  especially  in  primiparse, 
whose  history  does  not  throw  any  light  on  the  possibility  of  bring- 
ing forth  a  child.  Every  obstetrician  with  any  experience  will  have 
seen  cases  in  which,  on  account  of  a  pelvis  measuring  only  three 
inches  at  the  true  conjugate,  he  anticipated  a  very  difficult  delivery, 
and  prepared  himself  to  perform  some  operation,  and  in  which  a 
living  child,  sometimes  even  of  goodly  size,  was  born  by  nature's  sole 
efforts. 

Indications  based  on  pelvic  measurements  are  of  much  less  value 
than  one  would  think.  At  least  in  the  writer's  experience  too  large 
children  give  rise  to  more  obstetric  difficulties  than  the  narrowness  of 
the  pelvis.  The  practitioner  should,  however,  make  himself  acquainted 
with  pelvimetry,  since  by  that  he  often  may  obtain  valuable  informa- 
tion which  may  put  him  on  his  guard  against  impending  trouble.  But 
he  should  not  be  satisfied  with  finding  a  normal  pelvis  ;  he  should 


SYMPHYSEOTOMY.  643 

also  use  every  means  of  forming  an  opinion  of  the  size  of  the  child 
(pp.  187,  188).  This  is  a  point  that  is  almost  entirely  overlooked. 
Commonly  the  practitioner  has  no  idea  either  of  the  size  of  the  pelvis 
or  of  the  foetus,  and  it  is  only  lack  of  progress  in  spite  of  good  labor- 
pains,  insufficient  dilatation  of  the  os,  and  the  premature  rupture  of 
the  membranes  that  make  him  surmise  that  something  is  wrong. 

One  thing  which  the  youngest,  the  humblest,  the  least  experienced 
practitioner  may  do,  and  ought  to  do,  is  to  avoid  increasing  the  danger 
a  hundredfold  by  infecting  his  patient  in  his  examinations. 

But  even  if  the  patient  has  been  long  in  labor,  even  if  attempts  at 
forceps  delivery  have  been  made,  even  if  there  is  strong  suspicion  of 
puerperal  infection,  symphyseotomy  may  be  practised  to  advantage, 
which  in  my  opinion  is  so  great  a  point  in  its  favor  that  I  fervently 
hope  it  will  not  be  allowed  again  to  fall  into  desuetude,  but,  on  the 
contrary,  will  be  resorted  to  much  more  frequently  than  it  is  now. 
Both  my  cases  were  met  in  private  consultation  practice  and  belonged 
to  the  latter  category,  and  there  was  no  other  means  of  delivering 
the  women  than  by  performing  sympliyseotomy  or  by  killing  their 
splendid  foetuses,  and  by  inactivity,  perhaps,  causing  the  death  of  the 
mothers  too.  I  think  with  great  regret  of  cases  in  which  symphyse- 
otomy was  not  performed,  and  in  which  the  foetus  was  destroyed  by 
craniotomy,  and  sometimes  the  mother  died  subsequently  of  sepsis. 
If  doctors  only  would  practise  antiseptic  midwifery  and  seek  help  in 
time,  many  a  life  might  be  spared  that  now  is  extinguished  with  the 
perforator  or  falls  a  prey  to  the  no  less  deadly  microbes. 

Examination  of  the  Pelvis. — It  appears  from  the  above  that  the 
first  condition  for  a  rational  decision  as  to  the  propriety  of  performing 
symphyseotomy  is  the  exact  mensuration  of  the  pelvis  with  pelvime- 
ter and  the  hand,  in  which  respect  the  reader  is  referred  to  what 
has  been  said  above  (pp.  115-117). 

After  having  measured  the  pelvis,  the  mobility  of  the  sacro-iliac 
joints  must  be  tried  by  alternately  extending  and  flexing  the  extrem- 
ities and  abducting  the  bent  knees.  The  gait  of  the  patient  and  her 
previous  history  may  also  give  valuable  information  on  this  point. 

Examination  of  the  Foetus. — Of  no  less  importance  is  the  examina- 
tion of  the  foetus  according  to  the  rules  laid  down  above  (pp.  108, 
111,  187,  188,  398),  which  will  give  information  about  its  life,  size, 
presentation,  and  position. 

Examination  of  the  Soft  Portion  of  the  Parturient  Canal. — The 
accoucheur  should  finish  his  examination  by  careful  observation  of  the 
condition  of  the  cervix,  the  os,  the  membranes,  the  vagina,  and  the 
vulva,  which,  if  it  does  not  determine  his  choice  of  operation,  may 
guide  him  in  regard  to  the  time  and  preparations  for  it.  Symphyse- 
otomy should  not  be  performed  before  the  os  is  fully  dilated ;  but,  if 


644 


OBSTETRIC   OPERATIONS. 


it  is  not,  dilatation  may  be  obtained  artificially  as  described  above 
(p.  583),  especially  with  Barnes's  and  Champetier  de  Ribes's  bags. 
In  primiparte  there  mostly  is  considerable  resistance  of  the  vagina 
and  vulva,  which  also  can  be  overcome  with  Champetier" s  bag  or 
Braun's  colpeurynter. 

Anatomy. — As   for  any  other  operation,  the  accoucheur    should 
make  himself  fully  familiar  with  the  normal  anatomical  construction 


Veins  of  the  prevesical  space.  Front  view  of  the  bladder  and  dorsal  surface  of  the  clitoris,  the 
right  crus  of  which,  as  well  as  the  right  side  of  the  pehls,  has  been  cut  away.  P,  internal  pudic 
vein,  receiving  blood  from  the  dorsal  and  cavernous  veins  of  the  clitoris,  the  urethral  and  anterior 
vesical  veins,  as  well  as  from  below  from  the  bulb,  the  perineum,  and  the  anus,  which  have  been 
cut  short ;  V,  large  vesical  trunk,  receiving  the  blood  from  the  vesical  plexus,  which  anastomoses 
with  the  tributaries  of  the  internal  pudic  vein.    A  pin  has  been  placed  between  the  two  chief  veins. 

of  the  parts  he  is  going  to  invade.  Fig.  118  (p.  86)  shows  well  the 
thick  layer  of  fat  through  which  the  knife  has  to  go  in  an  incision 
above  the  symphysis.  Under  this  it  severs  the  superficial  fascia — 
generally  called  the  deep  layer  of  the  superficial  fascia — and  then  the 
aponeuroses  of  the  obliquus  externus,  obliquus  internus,  and  trans- 


SYMPHYSEOTOMY. 


645 


versalis   muscles  united  in  the  linea  alba  between  the  pyramidales 
muscles. 

This  brings  us  into  the  j^t^evesical  space,  or  cavum  Betzii,  situated  in 
front  of  the  transversalis  fascia.  The  loose  connective  tissue  found 
in  it  recedes  easily,  and  we  can  introduce  the  fmger  behind  the  sym- 
physis pubis,  in  front  of  the  bladder.  In  the  lower  part  of  this  space 
run  large  veins  (Fig.  464),  which  come  from  the  anterior  surface 
of  the  bladder,  from  the  urethra  and  the  clitoris.  These  vesical 
veins  form  large  plexuses  communicating  with  those  of  the  uterus, 
vagina,  vulva,  and  rectum,  and  sending  their  blood  to  the  internal  iliac 
vein. 

In  front  of  the  symphysis,  about  half-way  down,  is  the  body  of  the 
clitoris,  fastened  to  it  above  by  the  suspensory  ligament^  terminating  in 
front  in  the  glans,  and  separating 
behind  at  the  pubic  arch  into 
the  two  crura,  small  fibrous  cyl- 
inders attached  to  the  rami  of 
the  pubis  and  the  ischium  (Fig. 
465). 

The  symphysis  itself  consists 
of  an  interpubic  disk  and  liga- 
ments (p.  137),  the  superior,  an- 
terior, posterior,  and  inferior  pubic 
ligaments.  The  last  is  also  called 
the  subpubic  ligament,  and  must 
be  severed  or  loosened  in  order 
to  obtain  the  necessary  separa- 
tion in  symphyseotomy. 

Immediately  under  the  sub- 
pubic ligament  runs  in  the  me- 
dian line  the  dorsal  vein  of  the 
clitoris  which  ends  in  the  pudic 
plexus  surrounding  the  upper 
part  of  the  urethra.  On  each 
side  of  the  vein  runs  the  dorsal  artery  of  the  clitoris.  Close  under 
and  behind  the  subpubic  ligament  lies  the  strong  transverse  ligament 
of  the  jyelvis,  only  separated  from  the  subpubic  by  the  vessels.  Behind 
the  transverse  ligament  is  the  tinangular  ligament,  or  deep  fascia  of  the 
perineum,  and  above  that  the  rectovesical  fascia  of  the  pjelvis  (Fig.  466). 

These  fascise  are  liable  to  be  torn  in  symphyseotomy,  and  their 
relations  should  therefore  be  clearly  understood. 

The  deep  perineal  fascia  has  two  layers,  a  superficial  and  a  deep 
layer,  which  extend  from  the  transverse  ligament  of  the  pelvis  in  front 
to  a  line  a  little  in  front  of  the  anus,  behind  the  superficial  trans- 


Front  view  of  the  perineal  septum, — that  is, 
the  deep  perineal  fascia,  or  triangular  ligament, 
showing  the  entire  clitoris.  (Savage.)  1,  glans; 
2,  suspensory  ligament :  3,  crura  of  clitoris  ;  4,  sub- 
pubic ligament ;  5,  dorsal  vein  of  clitoris ;  6,  tri- 
angular ligament ;  7,  superficial  transverse  muscle ; 
s,  symphysis  pubis ;  «,  meatus  urinarius ;  r,  vagina ; 
P,  site  of  perineal  body. 


646 


OBSTETRIC    OPERATIONS. 


versus  peringei  muscle,  where  the  two  layers  coalesce  and  also  join 
the  superficial  fascia  of  the  perineum.  At  the  sides  these  fasciae  are 
attached  to  the  descending  ramus  of  the  pubis  and  the  ascending 
ramus  of  the  ischium. 

The  deep  perineal  fascia  is  perforated  by  the  urethra  and  the  va- 
gina. The  divided  symphysis  cannot  be  separated  to  any  great  extent 
without  putting  the  fibres  of  this  fascia  on  the  stretch  transversely, 
and  if  separation  is  continued  beyond  this  point,  the  fascia  must 
rupture.  The  tear  will  occur  at  the  weakest  point,  which  generally 
is  along  the  line  of  perforation,  and  will  involve  the  structures  that 

Fig.  466. 


Diagram  of  the  pelvic  floor  in  mesial  section.    (Dickenson.) 


pass  through  or  are  contiguous  with  this  fascia, — to  wit,  the  large  veins, 
the  clitoris,  the  urethra,  and  finally  the  vagina.  It  is  the  tearing  of 
these  structures  that  leads  to  most  of  the  dangers  and  complications 
of  the  operation, — hemorrhage,  sepsis,  urinary  fistula,  incontinence  of 
urine,  etc. 

In  the  vulva,  under  the  mucous  membrane  and  the  superficial 
perineal  fascia,  outside  the  entrance  to  the  vagina,  and  inside  of  the 
sphincter  vaginse  muscle,  lie  the  vestibulo-voginal  bulbs  (Fig.  467), 
which  are  chiefly  composed  of  veins  with  numerous  communications 
with  those  of  the  neighboring  parts.  Near  the  anterior  end  of  the 
bulb  they  go  from  one  side  to  the  other,  both  behind  and  in  front  of 


SYMPHYSEOTOMY. 


647 


the  meatus  urinarius,  forming  the  pars  intermedia,  and  from  here  they 
communicate  with  the  corpora  cavernosa  of  the  chtoris. 

3Iodus  Operandi. — Three  assistants  are  indispensable,  one  attending 
to  the  anaesthesia  and  one  on  each  side  holding  a  leg  and  assisting  at 
the  field ;  but  the  safety  of  mother  and  child  will  be  much  better 
guarded  by  having  one  more,  capable  of  replacing  the  operator  either 
as  accoucheur  or  surgeon.  When  delivery  is  accomplished,  there  often 
comes  a  critical  moment,  when  the  asphyxiated  baby  and  the  bleeding 
mother  require  equally  skilful  help,  which  cannot  be  rendered  by  the 
same  person. 

Table,  anaesthesia,  disinfection,  evacuation  of  bladder,  and  perhaps 
rectum,  as  usual.    The  patient  should  be  placed  in  the  dorsal  position, 


Fig.  46 


Front  view  of  the  external  erectile  organs.  Two-thirds  natural  size.  (Kobelt.)  a,  vestibulo- 
vaginal  bulb;  b,  sphincter  vaginae  muscle;  ee,  pars  intermedia;/,  glans  clitoridis ;  g,  connecting 
veins ;  h,  dorsal  vein  of  the  clitoris ;  k,  veins  passing  beneath  the  pubes ;  I,  obturator  vein. 

and  the  legs  should  be  held  bent  in  hip-  and  knee-joints,  moderately 
separated  and  with  the  feet  high.  This  is  done  by  the  assistants,  who 
on  command  of  the  operator  can  raise  or  lower  the  knees,  as  the 
extraction  of  the  child  may  require. 

Considerable  interest  attaches  to  the  question  about  the  place  and 
the  length  of  the  first  incision.  It  may  be  short,  medium,  or  long.  It 
may  be  above,  below,  or  in  front  of  the  symphysis.  The  symphysis 
may  be  cut  from  behind,  from  the  front,  from  above,  or  from  below. 
The  operation  may  be  open  or  subcutaneous. 

At  the  present  date  we  must  at  least  distinguish  four  separate 
methods,  and  for  convenience  I  shall  attach  a  man's  name  to  each  of 
them,  although  this  man  may  have  had  predecessors  who  have  done 
most  of  the  work.     Thus,  Morisani's  method,  according  to  himself, 


648 


OBSTETRIC    OPERATIONS. 


dates  from  Galbiati  at  the  end  of  the  eighteenth  century.  Pinard's  is 
the  original  Sigault  operation ;  Ayers's  is  conceded  partially  to  have 
been  suggested  by  Dawbarn/^  and  a  chief  point  in  it,  the  introduction 
of  a  probe-pointed  bistoury  through  a  small  opening  made  in  the  vesti- 
bule, was  already  recommended  by  Imbert,  of  Lyons,  France,  in  1833, 
and  mentioned  in  my  first  paper,  published  in  1893.  Harris  has  had 
a  precursor  in  Porak,'^  who  detached  the  triangular  ligament  from  its 
median  insertions. 

1.  MorisanVs  Method. — A  longitudinal  incision  3  centimetres  (1^ 
inches)  long  is  made  in  the  median  line,  ending  1  or  2  centimetres 
(|— I  inch)  above  the  symphysis.  Small  incisions  are  made  trans- 
versely into  the  recti  or  pyramidales  muscles  to  make  room  for  the 
index-finger,  which  he  inserts  behind  the  symphysis  to  the  lower  end 
of  the  same.  Next  he  introduces  a  sickle-shaped  knife,  GalbiaWs 
falcetta  (Fig.  468). 

Fig.  468. 


iziiBia 


Galbiati's  falcetta. 


The  figure  is  a  photograph  of  a  knife  I  got  from  Morisani  in  1883, 
Later  I  had  it  modified  according  to  the  principles  of  aseptic  surgery, 
and  now  it  is  made  of  one  piece  of  steel  without  any  furrows  (Fig. 
469).     This  sickle-shaped  instrument  is  inserted  alongside  of  the  left 


Fig.  469. 


Galbiati's  falcetta  as  modernized  by  the  author. 


index-finger,  which  is  held  against  the  posterior  surface,  down  to  the 
pubic  arch.  When  the  point  has  passed  this,  the  handle  is  gradually 
pulled  upward  and  forv/ard,  severing  the  symphysis,  inclusive  of  the 
subpubic  ligament,  from  below  upward.  The  urethra  is  protected 
against  injury  by  being  held  over  to  the  patient's  right  side  by  means 


SYMPHYSEOTOMY.  649 

of  a  male  metal  catheter,  which  at  the  same  time  serves  to  keep  the 
bladder  empty. 

After  having  severed  the  symphysis,  Morisani  leaves  the  case  to 
nature  if  the  pains  are  good,  but  in  about  one  case  out  of  four  traction 
with  forceps  has  been  found  necessary.  He  is  opposed  to  delivery  by 
version. 

2.  Pinarcfs  Method. — The  incision,  8  or  10  centimetres  (3-4  inches) 
long,  begins  at  or  above  the  upper  end  of  the  symphysis  and  ends 
at  the  root  of  the  clitoris,  or,  if  necessary,  deviates  to  the  left  of  it. 
The  symphysis  is  severed  from  the  front  backward  and  from  above 
downward.  Some  suitable  blunt,  flat,  curved  instrument  is  held 
behind  the  symphysis  to  protect  the  bladder, — for  instance,  Hay's 
director  (Fig.  470)  or  Farabeuf  s  gorgeret. 

Fig.  470. 


Hay's  director. 

3.  Ayers''s  Method}* — A  small  incision  is  made  with  a  scalpel  about 
^  inch  (1  centimetre)  below  the  clitoris.  The  left  index-finger  is  intro- 
duced into  the  vagina  up  to  the  upper  end  of  the  symphysis,  and  a 
curved  probe-pointed  bistoury  is  passed  through  the  wound,  close 
against  the  joint,  to  the  top  of  the  symphysis.  The  blade  now  lies 
under  the  vessels  of  the  clitoris  and  in  front  of  the  symphysis,  and 
need  not  cut  any  arteries.  The  tip  of  the  bistoury  and  the  tip  of  the 
finger  in  the  vagina  are  brought  together  at  the  top  of  the  joint. 
Then  the  bistoury  is  worked  downward,  the  finger  in  the  vagina  ac- 
companying it  to  within  ^  inch  (|  centimetre)  of  the  pubic  arch. 
Then  the  bistoury  is  taken  out,  inverted,  and  made  to  cut  upward, 
thus  avoiding  the  pars  intermedia  of  the  bulbs  of  the  vestibulum. 

When  the  knife  is  removed,  a  pad  of  bichloride  gauze  is  pressed 
against  the  wound  and  surface  of  the  severed  joint  until  the  foetus  is 
delivered.     This  is  intended  to  prevent  hemorrhage  and  infection. 

4.  Hai^ris's  Method}^ — An  incision  4-5  centimetres  (li-2  inches) 
in  length  is  made  from  a  little  above  the  symphysis  to  1  centimetre 
(I  inch)  above  the  clitoris.  The  suspensory  ligament  is  detached,  and 
the  clitoris  pulled  down  with  a  retractor  in  the  lower  angle  of  the 
wound.  While  cutting  the  symphysis,  the  legs  are  held  firmly  to- 
gether, to  prevent  a  sudden  rupture  in  case  of  a  labor-pain  occurring. 
After  separating  the  soft  tissues  well  from  the  symphysis  in  front  and 
behind,  the  symphysis  is  divided  from  above  downward  to  the  sub- 
pubic ligament,  which  is  left  intact.  Next,  this  ligament  and  the  tri- 
angular ligament  are  carefully  detached  from  the  bones  forming  the 


650  OBSTETRIC    OPERATIONS. 

pubic  arch  with  a  blunt-pointed  bistoury,  the  fmger  protecting  the 
neighboring  soft  part,  and  tlie  knife  being  kept  close  to  the  bone,  within 
a  distance  of  3  or  4  centimetres  (IJ  inches)  on  eacli  side.  As  this 
detachment  proceeds,  the  symphysis  gradually  opens,  and  it  should  be 
continued  until  the  symphysis  is  fully  separated,  and  no  more  tense 
fibres  are  felt  stretched  between  the  rami  (Fig,  471). 

And  now,  which  of  these  methods  shall  we  choose  ?  In  my  first 
operation  I  followed  Pinard,  and  had  a  good  deal  of  trouble  with 
hemorrhage  and  sepsis.  In  my  second  I  acted  strictly  according 
to  Morisani's  prescriptions,  except  that  I  extracted  with  forceps  im- 
mediately after  cutting  the  syrnphysis,  and  I  found  it  much  more 
satisfactory.  And  when  I  have  the  opportunity  of  performing  another 
operation,  I  think  my  choice  will  be  Harris's  method. 

Those  who  have  made  the  long  incision  have  had  much  more 
trouble  to  contend  with  than  those  who,  like  Morisani  and  Ayers,  use 
a  subcutaneous  method  ;  but  it  is  certainly  more  surgical  to  see  what 
one  is  doing,  and  to  arrest  hemorrhage  according  to  general  surgical 
principles.  Ayers's  method  exposes  the  large  veins  behind  and  at 
the  lower  end  of  the  symphysis  to  being  wounded.  The  incision  in 
the  vulva  contains  a  serious  element  of  danger  as  to  infection.  It  is 
a  general  experience  that  of  all  tissues,  bones  and  articulations  are 
most  apt  to  become  infected,  and  it  is  impossible  to  render  the  vulva 
and  the  v^ina  aseptic. 

Harris's  method  is  based  on  solid  anatomical  ground :  the  wound 
remains  two  inches  above  the  meatus  urinarius  ;  and  hemorrhage  and 
tears  are  avoided  by  separating  the  soft  parts  from  the  symphysis  in 
front  and  behind,  by  not  cutting  the  subpubic  ligament,  and  by  loosen- 
ing it  and  the  deep  perineal  fascia  from  their  attachments. 

If  the  head  is  impacted  in  the  pelvis,  it  is  not  possible  to  introduce 
the  finger  into  the  prevesical  cavity  of  Retzius  or  into  the  vagina,  and 
it  may  then  be  necessary  to  cut  the  symphysis  from  the  front,  with- 
out any  protection  behind. 

When  the  symphysis  is  severed,  it  should  be  cautiously  separated 
to  the  full  extent  allowed  by  the  sacro-iliac  articulations,  before 
attempting  deliver}'",  which  is  much  safer  than  to  use  the  fcetus  itself 
as  a  dilator,  which  may  cause  the  gap  in  the  symphysis  suddenly  to 
spread,  lacerating  the  urethra  and  vagina,  and  giving  rise  to  severe 
hemorrhage. 

I  did  not  find  any  difficulty  in  my  first  case  in  using  the  ordinary 
curved,  probe-pointed  bistoury  represented  in  Fig.  473. 

Paul  ZweifeV*^  in  order  to  prevent  stagnation  of  fluid  and  conse- 
quent absorption  and  infection,  perforates  the  bottom  of  the  prevesical 
space  with  a  curved  trocar,  which  is  pushed  out  at  the  side  of  the 
urethra.     It  has  a  lumen  of  eight  millimetres,  through  which  he  car- 


CAB 


G  DBF 


Fig.  iTl.— S}-mphyseotomy  by  Harris's  method,  front  view.  (Diagram.)  A,  incision  tiirough 
symphysis  prolonged  along  the  pubic  arch  (red) ;  i?,  clitoris  with  its  crura  drawn  up  (dotted) ; 
C,  subpubic  ligament,  or  ligamentum  arcuatum ;  D,  vena  dorsalis  clitoridis ;  E,  entrance  to  the 
vagina  ;  F,  urethra  ;  G,  triangular  ligament,  or  deep  perineal  fascia. 


B    C  D  A 


Fig.  -IT-i.— Symphyseotomy  by  Harris's  method.  Side  view.  (Diagram.)  .1,  inc'isioii  to  reach 
.symphy.si.s ;  B,  clitoris;  C,  vena  dorsalis  clitoridis;  D,  symphysis  pubis;  E,  urethra;  F,  prevesical 
space,  or  cavum  Retzii ;  G,  vagina ;  //,  anus ;  I,  uterus  ;  J,  bladder. 


SYMPHYSEOTOMY.  651 

ries  a  rubber  tube.  The  upper  end  of  this  comes  to  lie  behind  the 
stitched  aponeurosis,  and  is  fastened  here  with  a  silkworm  gut,  which 
is  carried  around  a  pledget  of  gauze  and  tied  with  a  half  hitch.  On 
the  fourth  day  this  ligature  is  loosened,  the  gauze  removed,  and  the 
drainage-tube  shortened  one  centimetre  (half  an  inch),  which  is 
repeated  daily.  If  unexpectedly  he  encounters  foul  hquor  amnii,  the 
opening  in  the  vestibulum  might  give  rise  to  infection,  and  he  there- 
fore pushes  the  trocar  through  the  labium  majus  so  as  to  come  out 
on  its  skin-covered  surface.  The  cases  thus  treated  with  drainage  had 
an  absolutely  feverless  course. 

If  the  obstetrician  has  the  case  in  hand  from  the  beginning,  it  is 
tetter,  in  the  interest  of  both  mother  and  foetus,  not  to  try  delivery  by 
forceps  before  proceeding  to  perform  symphyseotomy.     But  in  most 

Fig.  473. 


Curved,  blunt-pointed  bistoury. 

cases  such  attempts  have  been  made  by  others  before  the  patient 
comes  under  his  observation. 

When  the  symphysis  has  been  separated,  the  wound  should  be 
packed  with  iodoform  gauze  or  plain  sterilized  gauze,  either  dry 
or  wrung  out  of  creolin,  which  combines  antiseptic  and  haemostatic 
powers. 

A  point  of  great  importance  to  settle  is  the  question  in  what  way, 
if  any,  labor  shall  be  furthered  beyond  cutting  the  symphysis.  Some 
leave  the  case  to  nature.  As  a  rule,  spontaneous  delivery  will  soon 
follow  the  enlargement  of  the  pelvis,  but  some  have  waited  in  vain  for 
a  whole  hour.  During  this  waiting,  pressure  on  the  trochanters  must 
be  kept  up  to  avoid  too  great  a  distention.  The  membranes  may  be 
broken  and  the  head  pressed  down  into  the  pelvis  from  above  and 
then  seized  with  forceps  or  enucleated  by  pressure  through  the  rectum. 
If  there  is  any  hemorrhage,  the  patient  should  be  delivered  at  once. 
It  is  also  an  advantage  to  do  so  while  she  is  anaesthetized.  It  seems 
that  the  forceps  has  given  better  results  than  version.  Still,  if  the  head 
is  not  engaged,  and  the  child  is  in  a  precarious  condition,  it  is  better 
to  turn  and  extract  it. 

Under  rare  circumstances  even  other  operations  may  become 
necessary,  such  as  embryotomy  of  the  dead  foetus,  or,  if  it  is  alive 
and  cannot  be  delivered  per  vias  naturales,  Caesarean  section. 

Exceptionally,  the  symphysis  may  be  a  synostosis  instead  of  a 
synchondrosis,  in  which  case  it  must  be  severed  with  a  chain-saw  or 
chisel  and  mallet.  Some  prefer  then  to  go  a  little  to  one  side  of  the 
median  line,  where  the  bone  is  thinner — -pubiotomy. 


652  OBSTETRIC   OPERATIONS. 

Sometimes  the  ends  of  ttie  bones  form  irregular  protrusions,  which 
prevent  cutting  the  cartilage  with  one  stroke.  Perhaps  it  may  be 
possible  to  follow  the  sinuosities  of  the  bones  with  a  small  knife. 
Sometimes  the  protuberances  have  yielded  to  strong  traction  on  the 
Galbiati  knife,  and  in  other  cases  recourse  had  to  be  taken  to  the  saw. 

If  the  placenta  does  not  follow  the  child  within  a  quarter  of  an 
hour,  it  is  better  to  detach  it  artificially. 

After  the  birth  of  the  child  and  the  removal  of  the  placenta,  the 
bones  should  be  brought  together  by  pressing  on  the  trochanters.  The 
fibrous  tissue  in  front  of  the  symphysis  may  be  united  by  catgut  or 
silk  sutures,  but  these  sutures  have  sometimes  given  rise  to  suppura- 
tion and  secondary  injury  to  the  urethra,  and  the  author  does  not 
deem  any  buried  sutures  necessary.  All  that  is  needed  is  to  carry  the 
deep  sutures  through  the  skin,  the  adipose  and  fibrous  tissue  down  to 
the  bone,  and  comprise  from  :^  to  J  inch  (|-1  centimetre)  of  the 
fibrous  tissue  on  either  side.  When  all  the  sutures  are  in  place, 
the  trochanters  are  pressed  together,  particular  care  being  taken 
that  the  bladder  and  the  vagina  do  not  get  in  between  the  ends 
of  the  bones ;  and  all  sutures  are  drawn  tight  and  closed  from  above 
downward.  One  or  more  superficial  sutures  may  be  needed  for  a 
perfect  adaptation  of  the  edges  of  the  cutaneous  wound.  For  these 
sutures  silk  answers  every  purpose.  Silkworm-gut  is  rather  short, 
and  silver  wire  takes  more  time  to  apply  and  causes  more  pain  in 
being  removed. 

In  order  to  prevent  the  bladder  from  being  caught  between  the 
ends  of  the  pubic  bones,  Dawbarn  advises  to  fill  it,  whereby  it 
becomes  globular  and  recedes  from  the  gap  in  the  symphysis. 

The  sutures  should  be  removed  after  eight  or  ten  days. 

Besides  the  sutures  in  front  of  the  severed  symphysis,  the  ends 
of  the  bones  should  be  approximated  by  pressure  exercised  on  the 
trochanters.  In  my  cases  I  surrounded  the  pelvis  with  three  straps 
of  rubber  adhesive  plaster,  two  inches  wide,  which  were  tightened 
around  the  trochanters,  each  covering  the  preceding  one  in  half  its 
width,  and  crossed  on  the  abdomen,  just  above  the  wound,  while  the 
legs  were  kept  stretched  out.  These  straps  remained  in  place  for 
nineteen  days  in  the  first  case  and  were  renewed  on  the  thirteenth 
day  in  the  second  because  they  had  become  loose.  This  treatment 
gave  entire  satisfaction.  The  straps  keep  the  ends  of  the  bones  in  con- 
tact, they  are  water-proof,  and  allow  one  to  lift  the  patient  without 
causing  any  pain,  by  simply  taking  hold  of  the  hips,  while  another 
person  places  the  bed-pan  under  the  patient. 

Others  have  placed  the  patient  on  a  cot  with  a  hole  cut  out  to 
allow  discharges  from  the  bladder  or  bowels  to  reach  a  vessel  placed 
underneath  ;  or  lifted  the  patient  in  a  wide  canvas  sling  fastened  to  a 


SYMPHYSEOTOMY. 


653 


hook  in  the  ceiHng ;  or  constructed  a  special  bed  filling  the  double 
indication  of  keeping  up  pressure  on  the  trochanters  and  lifting  the 
patient ;  or  compressed  the  trochanters  with  a  metal  girdle  with  hol- 
low tampons,  which  are  screwed  against  the  trochanters.  All  this  is 
ingenious,  but  in  the  writer's  opinion  superfluous  and  more  or  less 
expensive. 

After  removal  of  the  plaster  straps  I  used  for  a  short  time  a  broad 
bandage  (Fig.  474)  of  gray  coutil,  with  three  straps  and  buckles.     It 

Fig.  474. 


Garrigoies's  symphyseotomy-bandage. 


measures  90  centimetres  (35J  inches)  at  the  top,  93  centimetres  (36J 
inches)  at  the  bottom,  and  is  14  centimetres  (5J  inches)  high.  This  is 
removed  when  the  patient  uses  the  bed-pan. 

The  wound  should  be  dressed  according  to  ordinary  rules  of  sur- 
gery.    The  vulva  should  be  covered  with  my  pad  (p.  201,  Fig.  228). 

Although  injuries  occurring  during  the  operation  occasionally  may 
heal  spontaneously,  it  is  much  better  to  repair  them  immediately  with 
catgut  sutures.  If  the  bladder  is  torn,  the  tear  should  be  closed  with 
continuous  catgut  tier-sutures,  one  applied  to  the  mucous  membrane, 
the  other  to  the  muscular  coat  and  the  peritoneum. 

If  there  are  no  complications,  the  patient  may  safely  leave  the  bed 
at  the  end  of  three  weeks,  and  be  dismissed  a  week  later.  Perhaps 
the  period  of  rest  may  even  be  shortened  to  two  weeks.^'' 

The  patient  should  he  with  outstretched  legs,  not  bent  over  a  roll, 
as  the  straight  position  in  itself  brings  the  ends  of  the  pubic  bones 
together;  and  the  knees  should  be  prevented  by  a  bandage  from 
separating  so  much  (p.  202,  Fig.  229,  4,  and  p.  544,  Fig.  398)  as  to 
have  any  influence  on  the  symphysis. 

Experiments  on  animals  have  shown  that  the  cells  in  the  severed 
cartilage  multiply  at  the  expense  of  the  hyaline  substance  and  form 
a  cicatrix  of  connective  tissue,  which  slowly  undergoes  retrograde 
metamorphosis.     In  most  cases  there  is  a  linear  union  without  any 


654  OBSTETRIC   OPERATIONS. 

appreciable  enlargement  of  the  symphysis,  but  in  others  there 
remains  a  fibrous  band  between  the  pubic  bones.  In  such  cases  sym- 
physeotomy has  not  only  a  passing,  but  a  permanent  effect  on  the  size 
of  the  pelvis,  which  explains  why  some  women,  who  had  been  deliv- 
ered by  symphyseotomy,  in  a  subsequent  pregnancy  gave  birth  to  a 
live  child  by  normal  labor.  In  a  case  in  which  symphyseotomy  had 
been  performed,  the  pubic  bones  separated  two  fmger-breadths  during 
the  following  labor  and  then  retracted  again.^'^  Among  twenty-five 
symphyseotomized  women  in  the  Leipsic  clinic  fourteen  became  preg- 
nant again,  and  on  only  one  the  operation  had  to  be  repeated.^ 

It  is  highly  gratifying  to  hear  that  in  forty-seven  symphyseotomies 
performed  in  the  United  States  and  Canada  up  to  1896,  by  forty-two 
different  operators,  perfect  union  and  normal  gait  were  obtained  in 
every  case.^* 

Bar^^  says  that  decubitus  acutus  is  not  very  rare  after  symphyse- 
otomy. This  is  a  unilateral  gangrene  which  sometimes  complicates 
operations  in  which  the  nerves  of  the  pelvis  are  pinched  or  otherwise 
irritated.  On  one  side  of  the  crest  of  the  sacrum  and  the  correspond- 
ing part  of  the  nates  appears  suddenly  an  erythematous  spot  with  a 
more  or  less  regular  contour,  rather  sensitive  to  touch,  and  accompa- 
nied by  a  pronounced  swelling  of  the  derma  and  subjacent  tissues. 
There  is  a  rise  in  temperature,  and  the  general  condition  is  bad.  In 
the  course  of  a  few  hours  blebs  filled  with  a  reddish  fluid  are  pro- 
duced on  the  erythematous  area,  and  in  two  or  three  days  an  eschar  is 
formed  as  large,  at  least,  as  the  hollow  of  the  hand,  and  implicating  all 
the  soft  parts  down  to  the  bone.  Later  this  eschar  is  thrown  off  and 
the  wound  filled  by  granulation. 

There  is  no  necessity  for  any  special  diet,  but  great  attention  must 
be  paid  to  cleanliness. 

In  a  Naegele  pelvis  delivery  has  been  accomplished  by  an  opera- 
tion called  ischiopubiotomy.  On  the  side  where  the  ankylosis  of  the 
sacro-iliac  joint  is  found,  the  pelvis  is  cut  with  a  chain-saw  in  two 
places, — namely,  in  the  ascending  branch  of  the  pubis  5  centimetres  (2 
inches)  from  the  median  line,  and  where  the  descending  ramus  joins 
the  ascending  ramus  of  the  ischium. 

The  patient  being  in  the  dorsal  position,  with  bent  and  separated 
knees,  an  incision  is  made  parallel  to  the  median  line  and  at  a  distance 
from  it  of  4  centimetres  (1|  inches)  in  the  direction  of  the  ankylosed 
sacro-iliac  joint.  The  middle  of  this  incision  is  on  a  level  with  the 
fourchette.  The  point  where  the  descending  branch  of  the  pubis  and 
the  ascending  branch  of  the  ischium  meet  is  exposed,  rasped  with  a 
raspatory  at  the  point  Avhere  the  chain-saw  shall  bite,  which  is  passed 
behind  the  bone,  from  within  outward. 

In  order  to  reach  the  horizontal  branch  of  the  pubis,  the  operator 


SYMPHYSEOTOMY.  655 

feels  for  the  spine  of  the  pubis  and  makes  an  incision  in  the  abdomen, 
4  centimetres  (If  inches)  from  the  median  Hne  and  parallel  to  it,  or 
about  a  finger's  breadth  outside  of  the  spine  of  the  pubis.  This  incision 
is  5  centimetres  (2  inches)  long.  It  begins  fully  a  finger's  breadth 
above  a  line  drawn  from  the  spine  of  the  pubis  to  the  anterior  supe- 
rior spine  of  the  ilium.  It  lies  outside  of  the  external  inguinal  ring. 
The  pectineus  muscle  is  split ;  the  bone  is  rasped  with  the  raspatory 
and  cut  with  the  chain-saw. 

After  the  bones  are  cut  it  is  necessary  bluntly  to  separate  the  ob- 
turator membrane  along  the  outer  border  of  the  ischiopubic  branches 
in  order  to  obtain  a  separation  of  the  ends. 

By  the  gaping  of  these  bones,  combined  with  the  mobility  at  the 
symphysis  and  the  other  sacro-iliac  articulation,  space  enough  is  gained 
for  the  passage  of  the  head. 

Relation  to  other  Operations. — Symphyseotomy  ought  to  replace 
craniotomy  on  the  living  foetus  whenever  it  is  possible  to  perform  the 
former.  Under  such  circumstances  it  would  be  next  to  murder  to  kill 
the  foetus ;  and  even  craniotomy,  which  deliberately  destroys  one  of 
the  two  lives  at  stake  in  a  delivery,  is  not  without  danger  to  the  other. 
Even  with  skilful  treatment,  it  is  accompanied  by  a  maternal  mor- 
tality of  5.6  per  cent.^" 

Induction  of  premature  labor  entails  a  maternal  mortality  of  only  5 
per  cent.,  but  then  the  infantile  mortality  is  about  50  per  cent.  In  cases 
in  which  the  mother's  life  is  to  be  preferred  to  that  of  the  child,  which 
is  the  rule,  and  we  see  the  patient  in  time,  recourse  may,  therefore,  be 
had  to  induction  of  premature  labor ;  but  in  cases  in  which  the  mother 
is  particularly  anxious  to  have  a  child,  symphyseotomy  within  the 
above-indicated  limits  should  be  preferred. 

The  comparison  with  Ccesarean  section  will  be  taken  up  later, 
when  we  have  described  that  operation. 

Even  difficult  forceps  and  version  operations  ought  to  be  replaced 
by  symphyseotomy.  If  the  true  conjugate  is  less  than  3  inches  (7|- 
centimetres),  it  is  better  not  to  try  to  deliver  with  forceps,  which 
may  cost  the  life  of  the  foetus  and,  perhaps,  that  of  the  mother  too. 
I  have  painful  recollections  of  cases  with  generally  contracted  pelvis 
of  the  male  type,  in  which  with  all  my  strength  I  extracted  a  dead 
child,  and  the  mother  died  within  a  few  days  from  sepsis.  All  those 
cases  we  read  about  of  three  strong  men  pulling  at  once  or  in  succes- 
sion on  a  pair  of  forceps  inserted  into  a  woman's  pelvis  ought  to  be 
relegated  to  the  history  of  barbarous  times. 

If  the  true  conjugate  is  less  than  S^  inches  (8  centimetres),  both 
version  and  the  high  forceps  operation  entail  much  greater  danger  for 
the  life  of  both  mother  and  foetus  than  does  symphyseotomy,  to  which 
must  yet  be  added  the  danger  of  the  child  becoming  idiotic  or  epileptic. 


656  OBSTETRIC   OPERATIONS. 

Symphyseotomy  is  of  particular  value  to  us  in  the  eastern  cities, 
where  we  so  often  meet  cases  of  pelvis  of  the  male  type  ;  and  if  the 
foetus  is  unusually  large,  symphyseotomy  comes  in  as  a  life-saving 
operation  for  both  mother  and  foetus,  even  when  the  pelvis  is  normal. 

With  a  normal  child  the  following  rule,  based  on  the  length  of  the  true 
conjugate,  may  be  of  some  value :  From  10.5  to  9  centimetres  (4^-3J 
inches),  forceps  or  version ;  from  9  to  7  centimetres  (3J-2|  inches), 
induced  premature  labor  or  symphyseotomy ;  from  7  to  5  centi- 
metres (2|-2  inches),  Ceesarean  section,  if  the  foetus  is  living  ;  below 
5  centimetres  (2  inches),  Csesarean  section,  even  when  it  is  dead. 

To  these  measurements,  which  are  calculated  for  the  plain  flat 
pelvis,  must  be  added  at  least  5  millimetres,  or  i  inch,  if  there  is  an 
appreciable  narrowness  in  the  transverse  diameter  of  the  brim. 

Though  we  have  mentioned  as  a  strong  point  in  favor  of  symphys- 
eotomy, that  it  has  a  fair  chance  of  success  even  when  the  patient  has 
been  long  in  labor  and  antisepsis  has  been  indifferent,  the  chances 
are,  of  course,  much  better  if  the  operation  is  performed  early  and 
before  any  infection  occurs.  Now  that  we  know  the  limits  of  the 
operation,  we  ought  in  proper  cases  to  urge  its  performance  as  soon 
as  labor  is  sufficiently  advanced.  After  that,  delay  only  causes  un- 
necessary suffering  and  suspense  to  the  mother,  adds  to  the  danger  of 
sepsis,  and  threatens  the  life  of  the  foetus. 

Who  shall  perform  Symphyseotomy  f — Nobody  should  undertake  this 
operation  who  is  not  an  operative  gynaecologist  or  a  general  surgeon 
with  obstetric  experience.  In  some  cases  serious  hemorrhage  has  to 
be  checked,  in  others  severe  injuries  of  delicate  and  important  organs 
demand  immediate  repair,  and  in  most  the  child  has  to  be  artificially 
revived  from  its  asphyxia.  But  even  with  this  restriction  I  do  not 
doubt  there  are  numerous  practitioners  in  the  United  States  capable 
of  meeting  all  complications  likely  to  arise  in  the  performance  of  sym- 
physeotomy. The  operator  must,  however,  have  proper  assistance,  as 
described  above,  and  there  must  be  means  of  carrying  out  the  after- 
treatment.  As  it  is  next  to  impossible  to  perform  an  aseptic  opera- 
tion in  most  private  dwellings,  especially  those  of  the  poor,  who  are 
much  more  likely  to  require  symphyseotomy  than  the  rich ;  as  many 
skilled  assistants  are  required  ;  and  as  the  after-treatment  often  is  quite 
complicated ;  the  chances  with  this,  as  with  all  major  surgical  opera- 
tions, are  much  better  in  a  well-equipped  hospital  than  in  private 
houses. 

REFERENCES. 

1.  Treub,  Annales  de  Gynecol.,  1893,  vol.  xi.  p.  377. 

2.  Tellier,  quoted  by  M.  L.  Harris,  Amer.  Jour.  Obst.,  1894,  vol.  xxx.  p.  762, 

3.  M.  Paul  Bar,  Pathologie  obstetricale,  Paris,  1900,  p.  94. 

4.  Polk,  Centralbl.  fiir  Gynakologie,  1899,  vol.  xxiii.  p.  362. 


GASTRO-ELYTROTOMY.  657 

5.  Abel,  Centralbl.  f.  Gynilk.,  1900,  vol.  xxiv.  p.  68. 

6.  Rubinroth,  Obstetrics,  1899,  vol.  i.  p.  664. 

7.  Bar,  1.  c,  p.  105. 

8.  Pinard,  Obstetrics,  1899,  vol.  i.  p.  543. 

9.  Bar,  1.  c,  p.  107. 

10.  Pinard,  Annales  de  Gynecol.,  Jan.,  1894. 

11.  Leopold,  Obstetrics,  Oct.,  1899,  vol.  i.  p.  544. 

12.  R.  H.  M.  Dawbarn,  Amer.  Jour.  Obst.,  1896,  vol.  xxxiii.  p.  359. 

13.  Porak,  Annales  de  Gynecol.,  Sept.,  1892. 

14.  E.  A.  Ayers,  N.  Y.  Polyclinic,  1896,  vol.  vii.  pp.  129-139. 

15.  M.  L.  Harris,  Amer.  Jour.  Obst.,  1894,  vol.  xxx.  p.  760. 

16.  P.  Zweifel,  Centralbl.  f.  Gynak.,  1902,  vol.  xxvi.,  No.  13,  p.  325. 

17.  Fieux,  Obstetrics,  1900,  vol.  i.  p.  657,  and  1901,  vol.  ii.  p.  248. 

18.  Pozzoli,  Centralbl.  f.  Gynak.,  1899,  vol.  xxiii.  p.  857. 

19.  Bar,  1.  c,  p.  104. 

20.  Wyder,  Archiv  f.  Gynak.,  1888,  vol.  xxxii.  p.  60. 


CHAPTER    XIII. 
GASTRO-ELYTROTOMY. 


Gastro-elytrotomy,  or  laparo-elytrotomy ^  has  that  in  common  with 
symphyseotomy  that  it  was  an  attempt  to  avoid  the  nearly  always 
fatal  Csesarean  section,  and  that  it  was  an  old  operation  which  had 
fallen  into  desuetude  when  in  our  time  it  was  brought  forth  again  in 
an  improved  shape.  But,  unlike  symphyseotomy,  it  has  been  aban- 
doned again,  giving  way  for  the  revived  symphyseotomy  and  the 
improved  Csesarean  section. 

Since  now  it  has  only  historical  interest,  I  should  not  mention  it  at 
all  if  it  had  not  been  during  the  short  time  of  its  revival  a  strictly 
American  operation,  reinvented,  elucidated,  and  chiefly  performed  by 
American  obstetricians  ;  but  since  this  is  so,  a  brief  reference  to  it  may 
be  justifiable  in  an  American  text-book  of  obstetrics. 

The  operation  consists  in  making  an  incision  through  the  abdo- 
minal wall  parallel  to  Poupart's  ligament,  from  the  spine  of  the  pubis 
to  the  anterior  superior  spine  of  the  ilium,  except  the  peritoneum. 
This  is  lifted  until  the  uterovaginal  junction  is  reached.  The  vagina 
is  raised  up  to  the  wound  with  a  steel  sound  passed  within  it,  and  cut, 
and  the  opening  thus  made  is  dilated  with  the  fingers.  The  cervix  is 
pulled  into  the  wound  with  a  blunt  hook,  while  the  fundus  is  depressed 
in  the  opposite  direction,  and  the  foetus  extracted  with  hand  or  forceps. 

The  first  operation  of  this  kind  was  performed  by  Ritgen  in  Ger- 
many in  1821.     After  having  been  abandoned  on  account  of  the  bad 

'  Garrigues,  "On  Gastro-Elytrotomy,"  New  York  Med.  Jour.,  Oct.  and  Nov., 
1878;  "Additional  Remarks  on  Gastro-Elytrotomy,  with  Special  Reference  to 
Porro's  Operation,"  Amer.  Jour.  Obst.,  Jan.,  1883,  vol.  xvi.,  No.  1. 

42 


658  OBSTETRIC    OPERATIONS. 

results,  it  was  improved  by  T.  G.  Thomas,  of  New  York,  in  1870,  and 
performed  at  least  fourteen  times  by  him  and  his  followers.  The 
maternal  mortality  was  50  per  cent.,  the  infantile  43  per  cent.^  After 
the  improvement  in  the  Caesarean  section  in  1883,  the  operation  of 
gastro-elytrotomy  was  no  longer  used. 


CHAPTER    XIV. 

cj:sarean  section. 


CESAREAN  SECTION,  or  laparohysterotoTYiy^  is  an  operation  in  which 
the  foetus  is  delivered  through  an  opening  made  in  the  abdominal  wall 
and  that  of  the  uterus. 

The  operation  was  performed  after  death  in  the  classic  antiquity. 
On  the  living  woman  the  first  authentic  operation  was  performed  in 
1610  in  Wittenberg  in  Germany.  We  have  spoken  above  (p.  551)  of 
its  use  after  the  death  of  the  mother.  It  remains  to  discuss  its  appli- 
cability to  the  living  woman  and  describe  its  technique.^ 

Indications. — There  is  an  absolute  and  a  relative  indication  to  per- 
form Csesarean  section.  The  absolute  indication  holds  good,  whether 
the  foetus  is  alive  or  not.  It  is  present  when  the  foetus,  even  after 
craniotomy,  cannot  pass  the  genital  canal,  or  when  the  disproportion 
between  the  foetus  and  the  canal  is  so  great  that  the  delivery  through 
the  normal  passage  would  entail  greater  dangers  to  the  mother  than 
the  Csesarean  section. 

This  indication  may  be  due  to  tumors  that  cannot  be  replaced  or 
diminished,  but  in  general  the  cause  is  a  high  degree  of  deformity  of 
the  pelvis,  mostly  of  rhachitic  or  osteomalacic  origin. 

If  the  smallest  diameter  is  less  than  2  inches  (5  centimetres), 
there  is  absolute  indication  for  Caesarean  section.  Much  advanced 
carcinomatous  degeneration  of  the  cervix  may  also  come  into  this 
category  (p.  295). 

The  relative  indication  may  be  present  when  the  smallest  diameter 
measures  between  2  and  3  inches  (5  and  8  centimetres),  but  is  bound 
to  certain  conditions : 

1.  The  foetus  must  be  alive,  viable,  and  not  materially  deformed. 

^  Wyder,  Archiv  fiir  Gyniikologie,  1888,  vol.  xxxii.  p.  76. 

^  Garrigues,  "The  Improved  Cajsarean  Section,"  Amer.  Jour.  Obstetrics,  vol. 
xvi.,  April,  May,  June,  1883  (author's  first  case)  ;  "The  Improved  Cfesarean  Sec- 
tion," ibid.,  vol.  xix.,  Oct.,  1886;  "The  Improved  Cs-sarean  Section,"  Amer. 
Jour.  Med.  Sci.,  May,  1888  (author's  second  case)  ;  "A  Case  of  Improved  Caesarean 
Section,"  Clinical  Recorder,  vol.  i.,  No.  1,  Feb.,  1896  (author's  third  case)  ;  "The 
Technique  of  the  Improved  Caesarean  Section,"  International  Jour,  of  Surgery, 
March,  1896. 


CESAREAN   SECTION.  659 

A  hydrocephalic  fretus,  for  instance,  should  be  diminished  by  crani- 
otomy. 

2.  The  mother  must  be  in  good  condition.  Labor  must  not  have 
been  too  protracted,  say  not  over  twenty-four  hours.  No  very  active 
attempts  at  delivery  with  forceps  must  have  been  made.  The  case 
must  have  been  treated  with  antiseptic  and  aseptic  precautions,  and  it 
must  be  reasonably  sure  that  no  infection  has  taken  place.  Otherwise 
symphyseotomy  or  craniotomy  must  take  the  place  of  Cassarean  sec- 
tion, for  under  such  circumstances  the  mortality  becomes  so  great 
that  the  operation  is  no  longer  justifiable. 

3.  The  accoucheur  must  explain  to  the  patient  that  unless  some- 
thing is  done,  both  she  and  her  child  are  lost.^  If  it  is  a  favorable 
case,  he  may  in  good  conscience  tell  her  that  it  is  nearly  certain  that 
the  child  will  be  saved  and  that  her  own  risk  is  small  provided 
Cassarean  section  is  resorted  to  without  unnecessary  delay.  But  if 
the  case  is  one  that  comes  within  the  scope  of  symphyseotomy,  and 
this  can  be  performed,  he  must  tell  her  so,  and  state  the  chances  for 
mother  and  child.  And,  finally,  he  must  tell  her  that  perhaps  her 
life  may  be  saved  if  that  of  the  child  is  destroyed  by  craniotomy, 
supposing  he  is  willing  to  perform  this  operation  on  the  living  foetus. 

Ilodus  Operandi. — All  precautions  known  to  aseptic  and  antiseptic 
surgery  should  be  taken,  preferably  in  the  following  way.  Operating- 
gowns  and  caps,  towels,  gauze  pads,  and  silk  are  sterilized  by  moving 
steam.  The  operator  and  his  assistants  disinfect  their  hands  and 
arms  as  described  above  (pp.  188-190).  Those  accustomed  to  oper- 
ate with  rubber  gloves  had  better  don  them  for  the  occasion.  The 
bowels  are  emptied  before  the  operation  with  an  aperient  and  an 
enema,  and  at  the  last  moment  the  urine  is  drawn  with  a  catheter. 
The  patient  is  anaesthetized,  the  vulva  and  abdomen  shaved  and  disin- 
fected in  the  same  way  as  the  operator's  hands.  The  vagina  is  disin- 
fected by  pouring  sterilized  tinctura  saponis  viridis  into  it,  rubbing  it 
with  a  ball  of  absorbent  cotton  or  a  gauze  pad  held  in  a  dressing- 
forceps,  and  pouring  a  copious  amount — several  quarts — of  bichloride 
of  mercury  solution  (1 :  2000)  into  it,  followed  by  lysol  emulsion 
(1 :  100).  The  instruments  are  boiled  with  soda  (p.  594)  and  kept  on 
a  sterilized  towel. 

The  temperature  of  the  room  should  be  about  80°  Y.  The  patient 
should  be  warmly  dressed  and  placed  on  her  back  on  a  narrow  table 

^  European  text-books  speak  as  if  in  a  case  of  absolute  indication  for  Citsarean 
section  the  operation  should  be  performed  with  or  without  the  consent  of  the 
woman.  In  America  the  law  demands  that  the  operator  shall  obtain  the  patient's 
consent  to  perform  any  surgical  operation  on  her  person.  To  do  Caesarean  section 
on  her  against  her  will  would  be  a  felonious  assault,  and  if  she  died  in  conse- 
quence of  the  operation  the  surgeon  would  be  guilty  of  murder. 


660  OBSTETRIC    OPERATIONS. 

covered  with  quilts  or  blankets,  a  rubber  sheet  or  oil-cloth,  and  a 
common  sheet.  Her  legs  are  bent  at  the  knees,  and  the  feet  placed 
on  a  stool  at  the  end  of  the  table,  so  that  the  assistant  who  takes  care 
of  the  constrictor  may  have  easy  access  to  the  womb  without  being  in 
the  way  of  the  operator  and  the  other  assistant.  The  field  of  opera- 
tion is  surrounded  by  four  sterilized  towels,  pinned  together  and  to 
the  clothes  of  the  patient. 

By  percussion  the  operator  satisfies  himself  that  no  knuckles  of 
intestine  lie  in  front  of  the  uterus,  or  he  pushes  them  aside.  An 
incision  is  made  in  the  median  line  half  above  and  half  below  the 
umbilicus,  passing  to  the  left  of  the  same.  It  severs  first  the  skin, 
then  the  subcutaneous  adipose  tissues,  then  the  linea  alba,  and  finally 
the  preperitoneal  fat.  Bleeding  vessels  are  clamped  with  artery-forceps. 
Next,  the  peritoneum  is  lifted  up  with  two  such  forceps,  and  a  small 
incision  made  in  it,  through  which  the  index-finger  is  passed  into  the 
abdominal  cavity,  and  the  peritoneum  slit  open  to  the  same  extent  as 
the  skin.  The  incision  should  be  just  long  enough  to  turn  out  the 
uterus,  and,  on  account  of  the  elasticity  of  the  abdominal  w^all,  the 
opening  need  not  by  far  be  so  long  as  the  uterus,  but  only  about  six 
or  seven  inches  (15-18  centimetres). 

Next,  the  right  hand  is  introduced  into  the  abdominal  cavity  and 
used  to  turn  out  the  uterus,  seizing  it  by  the  left  corner.  If  necessary, 
this  movement  may  be  aided  by  pressure  from  the  vagina.  Before 
pulling  out  the  uterus,  three  or  four  long  silk  sutures  are  inserted 
through  the  lips  of  the  abdominal  wall  above  the  umbilicus,  an  mch 
apart.  The  two  ends  of  each  are  clamped  together.  As  soon  as  the 
uterus  is  lifted  out,  these  sutures  are  closed,  which  serves  to  keep  the 
intestine  and  the  omentum  away  from  the  field  of  operation. 

A  rubber  tube,  about  as  thick  as  the  little  finger  and  half  a  yard 
long,  is  laid  loosely  around  the  cervix  and  the  broad  ligaments  outside 
of  the  appendages  and  crossed,  but  not  tied,  so  that  the  assistant  in 
charge  of  this  constrictor  can  easily  tighten  or  loosen  it  according  to 
circumstances. 

The  uterus  is  enveloped  in  a  sterilized  cloth  wrung  out  of  hot 
normal  salt  solution,  and  a  large  dry  gauze  pad  is  placed  in  front  and 
behind,  under  which  it  is  well,  if  the  membranes  are  entire,  to  lay  a 
piece  of  sterilized  gutta-percha  tissue. 

At  the  moment  the  incision  is  begun,  the  constrictor  is  tightened. 
The  incision  is  made  in  the  median  line  of  the  anterior  wall  of  the 
uterus,  so  as  to  avoid  the  cervix  and  lower  uterine  segment,  where 
there  are  large  veins  and  much  less  contractility.  Above  it  must 
extend  far  enough  to  allow  the  hand  to  be  introduced  and  the  foetus 
to  be  withdrawn  with  ease, — say,  from  4|  to  5|  inches  (12-14  cen- 
timetres).    This  incision  is  made  with  many  repeated  strokes.     It  is 


CiESAREAN   SECTION.  661 

best  to  begin  with  a  convex,  sharp-pointed  bistoury,  and  when  an 
opening  is  made  into  the  cavity  the  left  index-finger  is  introduced, 
and  the  incision  extended  on  it  witli  scissors  or  a  probe-pointed 
bistoury.  Bleeding  sinuses  are  clamped.  If  the  placenta  is  inserted 
on  the  anterior  wall,  the  incision  is  carried  through  it. 

If  the  waters  have  not  broken,  the  operator  tears  the  ovum  near 
the  lower  end  of  the  incision,  taking  care  that  none  of  the  fluid  enters 
the  peritoneal  cavity,  especially  if  it  is  decomposed  or  contains 
meconium.  If  the  waters  have  drained  off  before  the  operation,  the 
operator  should  take  particular  care  not  to  wound  the  fcetus  in  making 
the  incision. 

When  the  ovum  is  opened,  the  operator  introduces  his  right  hand, 
and,  if  possible,  delivers  the  head  of  the  child  first,  whereby  the 
danger  of  the  uterus  contracting  in  front  of  it  is  avoided.  If  this  is 
not  easily  done,  he  seizes  an  extremity  or  the  body  and  pulls  the  child 
out  of  the  uterus.  The  cord  is  tied  immediately  with  two  ligatures 
and  cut  between  them,  and  the  child  is  handed  to  a  competent  nurse 
or  preferably  a  physician,  who,  if  necessary,  employs  the  usual  means 
of  reviving  it  (p.  559),  while  the  operator  continues  to  bestow  his 
attention  on  the  mother. 

If  the  placenta  is  cast  loose,  he  seizes  it  and  peels  off  the  mem- 
branes from  the  interior  of  the  womb,  so  as  to  have  all  the  afterbirth 
in  one  piece.  If,  on  the  other  hand,  the  placenta  still  adheres  to  the 
wall,  he  leaves  it  alone,  and  inserts  deep  silk  sutures  half  an  inch  from 
the  edge  through  the  whole  uterine  wall,  except  the  decidua.  There 
ought  to  be  about  |  inch  (2  centimetres)  between  each  two  sutures. 
The  ends  of  each  are  clamped  together.  By  the  time  this  is  done  the 
placenta  will  probably  have  been  cast  off ;  but,  if  it  has  not  yet  sepa- 
rated, he  peels  it  off  like  the  membranes,  which  always  are  adherent, 
before  tightening  the  sutures. 

If  the  operation  is  performed  before  the  cervix  is  dilated,  this 
should  be  done  now  manually,  so  as  to  insure  free  drainage  from  the 
uterus  to  the  vagina. 

If  any  part  of  the  foetus  or  the  membranes  has  been  caught  in  the 
constrictor,  this  must  temporarily  be  loosened. 

For  the  sutures  I  think  sterilized  silk  is  the  best  material,  a  medium 
thick — braided  No.  4 — for  the  deep,  and  a  fine — braided  No.  2 — for 
the  superficial.  Silver  wire  is  also  good,  but  takes  more  time,  and 
catgut  knots  are  liable  to  reopen  by  the  alternation  of  contraction  and 
relaxation  of  the  uterus. 

In  tightening  the  deep  sutures,  the  serous  surfaces  of  the  peri- 
toneum should  be  adapted  to  each  other,  so  as  to  lie  on  the  top  of  the 
wound,  but  not  drawn  in  between  the  cut  surfaces  of  the  muscular 
tissue. 


662  OBSTETRIC    OPERATIONS. 

When  these  deep  sutures  have  been-  tied,  superficial  ones,  only 
comprising  the  peritoneum,  are  inserted  midway  between  each  two  of 
the  deep.  They  are  likewise  inserted  half  an  inch  from  the  edges, 
but  are  pushed  out  again  a  cfuarter  of  an  inch  from  the  latter  and 
inserted  in  a  similar  way  on  the  opposite  side,  so  as  to  apply  broad 
surfaces  against  each  other. 

After  the  removal  of  the  after-birth,  clots  are  removed  from  the 
interior  of  the  womb,  and  it  is  simply  wiped  dry.  No  antiseptics  are 
needed,  nor  should  the  uterus  be  curetted. 

For  passing  the  deep  sutures  medium-sized,  round,  trocar-pointed, 
curved  needles  are  the  best ;  for  the  peritoneum  a  finer,  round, 
curved,  simply  pointed  needle  is  preferable.^ 

All  sutures  being  tied,  the  elastic  constrictor  should  be  loosened 
very  slowly,  since  a  sudden  rush  of  blood  into  the  uterus  is  apt 
to  cause  hemorrhage.  Nor  should  the  constriction  be  kept  up  longer 
than  absolutely  necessary,  as  it  is  apt  to  cause  atony  of  the  uterus. 
Hemorrhage  may  have  its  source  in  the  wound  or  on  the  placental 
site. 

The  uterus  ought  not  to  be  replaced  into  the  abdominal  cavity 
until  all  bleeding  has  stopped.  If  there  is  any,  it  is  checked  by  com- 
pression with  a  hot  sponge,  by  squeezing  the  uterus,  by  pouring  hot 
normal  salt  solution  over  the  outside  of  it,  by  adding  supplementary 
sutures  under  the  bleeding  spots,  or,  if  necessary,  by  administering  an 
intra-uterine  injection  of  normal  salt  solution  or  hot  water  with  the 
addition  of  creolin  or  liquor  ferri  chloridi  (1  per  cent.).  If  simple 
interrupted  sutures  do  not  suffice  to  check  hemorrhage,  a  mattress- 
suture  may  be  substituted.  A  curved  needle  is  introduced  on  a  line 
with  the  other  sutures,  passed  under  the  bleeding  sinus  and  out  on 
the  same  side.  A  similar  suture  is  inserted  at  the  corresponding  point 
of  the  other  lip  of  the  wound,  and  in  tying  the  sutures  the  two  upper 
ends  are  united,  and  so  are  the  two  lower  ones.  It  may  also  be  done 
with  a  single  thread,  going  from  above  downward  on  one  side  and 
from  below  upward  on  the  other. 

If  it  is  impossible  to  check  the  hemorrhage,  which  is  exceedingly 
rare,  nothing  else  is  left  than  to  amputate  the  uterus  by  Porro's  oper- 
ation (see  below). 

When  all  bleeding  has  ceased,  the  constrictor  is  removed,  the  peri- 
toneal cavity  is  cleaned  with  gauze  pads  held  in  long  forceps,  and  if 
decomposed  liquor  amnii  has  got  into  it,  it  is  washed  out  with  plenty 
of  warm  normal  salt  solution.  The  same  should  be  done,  if  much 
meconium  has  found  its  way  into  the  peritoneal  cavity ;  but  if  only  a 
little  has  entered,  it  is  better  to  wipe  it  off  dry  and  leave  an  iodoform 

^  John  Campbell,  228  Lexington  Avenue,  corner  Thirty-fourth  Street,  New- 
York,  keeps  these  needles  in  stock  under  my  name. 


CESAREAN    SECTION.  663 

gauze  drain  in  the  lower  end  of  the  incision.  The  uterus  is  replaced 
and  the  omentum  pressed  up  above  it,  in  order  to  avoid  adhesions 
that  may  lead  to  intestinal  obstruction.  The  abdominal  wound  is 
closed  with  deep  sutures,  comprising  the  whole  thickness  of  the  wall, 
and  in  passing  them  particular  care  is  taken  to  include  the  aponeuro- 
sis of  the  abdominal  muscles  and  the  peritoneum.  They  are  passed 
at  intervals  of  an  inch,  and  superficial  ones,  through  the  skin  alone, 
between  them.  For  the  deep  abdominal  sutures  I  prefer  silkworm 
gut,  for  the  superficial  fine  silk.  It  is  most  convenient  to  use  a  large, 
semicircular  Hagedorn  needle  for  closing  the  abdominal  wound. 

Dressing. — The  line  of  incision  is  dusted  with  eka  iodoform  and 
covered  with  a  pad  of  iodoform  gauze.  Outside  of  this  and  overlap- 
ping it  an  inch  in  all  directions  comes  a  piece  of  gutta-percha  tissue, 
which  adheres  closely  to  the  skin.  On  top  of  that  are  placed  pads  of 
sterilized  gauze,  a  layer  of  absorbent  cotton,  held  in  place  by  broad 
straps  of  adhesive  plaster,  and,  finally,  a  many-tailed  muslin  bandage. 

The  genitals  and  anus  are  covered  with  my  antiseptic  pad  as  in 
normal  deliveries,  which  pad  is  fastened  to  the  abdominal  bandage  and 
changed  four  times  a  day  or  oftener. 

After-treatment. — The  patient  is  placed  in  a  bed  with  half  a  dozen 
bottles  filled  with  hot  water,  especially  near  the  hands  and  feet. 

When  she  comes  out  from  under  the  anaesthesia,  vomiting  often  is 
an  embarrassing  symptom.  The  patient  should  then  be  made  to 
make  deep  inhalations  with  acetic  acid,  which  expels  the  remnants  of 
the  anaesthetic  from  the  deeper  part  of  the  lungs.  A  few  mouthfuls 
of  strong,  black  coffee  and  the  administration  of  the  compound  tincture 
of  iodine,  r^^l  every  hour,  have  proved  most  efficacious  to  the  author. 
Otherwise  she  is  only  given  teaspoonfuls  of  hot  or  ice-cold  water. 
Other  useful  remedies  are  cocaine,  hydrocyanic  acid,  nux  vomica,  cre- 
osote, carbolic  acid,  aerated  mineral  waters,  cracked  ice,  champagne, 
counter-irritation  of  the  pit  of  the  stomach,  etc. 

If  there  are  signs  of  shock,  strychnine  (gr.  ^V — 2  milligrammes — 
repeated  till  gr.  yV — ^  milligrammes — has  been  given),  tincture  of  digi- 
talis ("ix — 60  centigrammes — repeated  till  sss — 2  grammes — has  been 
used),  and  nitroglycerin  (gr.  y^-g — 0.6  milligramme — until  gr.  -^ — 2.4 
milligrammes — has  been  administered)  should  be  injected  hypodermi- 
cally.  Camphor  dissolved  in  four  parts  of  sterilized  olive  oil  may  be 
injected  (gss — 2  grammes)  into  the  deltoid  or  vastus  externus  muscle. 
Injection  of  hot  saline  solution  under  the  skin,  into  the  rectum,  or 
into  a  vein  is  especially  valuable  if  much  blood  has  been  lost  during 
the  operation.  The  foot  of  the  bed  should  be  raised,  so  as  to  insure  a 
proper  supply  of  blood  to  the  brain. 

Secondary  hemorrhage  may  occur  during  the  lying-in  period,  and 
should  be  treated  with  hypodermic  injection  of  stypticin  or  ergot,  and 


664  OBSTETRIC   OPERATIONS. 

intra-uterine  injection  with  hot  normal  salt  solution,  if  necessary  with 
diluted  liquor  ferri  chloridi.  Simultaneously  extract  of  suprarenal 
capsule,  or  adrenalin,  may  be  given  by  the  mouth  (p.  514). 

The  patient  should  be  kept  on  fluid  diet  for  a  week.  If  vomiting 
continues,  she  should  have  nothing  but  cold  milk  or  its  derivatives, — 
peptonized  milk,  kumiss,  zoolak,  or  junket, — and  always  in  very  small 
quantities.  In  a  very  obstinate  case  rectal  alimentation  might  be 
resorted  to.  Appropriate  mixtures  for  this  purpose  are  an  egg  beaten 
up  with  four  ounces  of  milk,  with  or  without  addition  of  an  ounce  of 
whiskey  ;  or  four  ounces  of  lean  beef — adding  water  enough  that  the 
mixture  can  be  injected  with  a  Davidson's  syringe.  After  the  first 
week  the  patient  may  have  full  diet. 

If  the  temperature  rises,  ice-bags  are  applied  to  the  head  and 
a  coil  with  ice-water  to  the  abdomen.  Antipyretic  drugs  are  all 
weakening  and  should,  therefore,  generally  be  avoided.  Peritonitis 
is  treated  either  with  large  doses  of  morphine  or  perhaps  prefera- 
ably  with  sodium  sulphate.  If  the  presence  of  a  cohection  of  pus 
around  the  uterus  is  diagnosticated,  the  lower  end  of  the  abdominal 
incision  should  be  opened,  a  hole  made  into  the  vagina,  and  drain- 
age established,  combined  with  antiseptic  injections  ;  or  an  incision 
may  be  made  in  the  vagina  from  below  and  drainage  secured  in 
that  way. 

The  bowels  are  moved  on  the  third  day.  The  abdominal  dressing 
is  changed  once  a  week.  The  sutures  are  removed  on  the  eighth  day 
and  replaced  by  narrow  strips  of  adhesive  plaster.  The  patient  stays 
in  bed  for  three  weeks,  and  should  wear  a  well-fitting  and  not  too 
yielding  abdominal  supporter,  such  as  Teufel's  (Fig.  240,  p.  240)  for 
the  next  three  months. 

On  the  above  pages  I  have  described  the  operation  with  all  the 
details  I  have  followed  in  my  own  operations. 

The  improved  Csesarean  section  is  a  beautiful  outgrowth  of  general 
surgical  and  special  gynaecological  development,  an  evolution  due  to 
the  combined  efforts  of  many  men  working  independently  of  one  an- 
other in  different  countries.  I  do  not  know  of  any  greater  mistake 
than  to  attach  a  single  man's  name  to  it.  In  a  special  paper  I  have 
shown  that  every  step  in  this  operation  had  not  only  been  used  by 
surgeons  and  gyneecologists  in  other  operations,  but  had  been  applied 
to  Caesarean  section  before  the  year  1882,  from  which  the  new  era  for 
the  operation  dates.^ 

There  are  many  modifications  of  the  way  of  operating,  to  discuss 
which  is  not  within  the  scope  of  a  work  of  this  kind  ;  but  one  is  so 
important  and  has  been  so  successful  that  it  calls  for  recognition  even 
in  a  text-book. 

iGarrigues,  Amer.  Jour.  Obst.,  1886,  vol.  xix.  pp.  1009-1022. 


CJISAREAN   SECTION.  665 

FritscKs  Method,  Transverse  Incision. — Professor  Heinrich  Fritscli, 
of  Breslau,  Germany,  makes  the  incision  in  the  uterus  transversely 
through  the  top  of  the  fundus  from  one  Fallopian  tube  to  the  other. 
This  seems  to  offer  several  advantages.  In  the  lirst  place,  the  placenta 
being,  as  a  rule,  inserted  on  the  anterior  or  tlie  posterior  wall  of  the 
uterus,  there  is  better  chance  of  avoiding  it  by  making  the  incision  at 
the  fundus  than  when  it  is  made  in  the  median  line.  Secondly,  the 
fundal  incision  avoids  altogether  the  lower  uterine  segment,  which 
often  has  given  rise  to  troublesome  hemorrhage,  and  the  limit  of  which 
cannot  be  made  out  before  the  contraction  ring  forms.  Thirdly,  the 
chief  course  of  the  uterine  vessels  being  from  the  edges  to  the  median 
line,  a  transverse  incision  is  likely  to  cut  fewer  of  them  than  the  longi- 
tudinal one.  The  results  have  been  excellent :  of  forty-seven  patients 
on  whom  the  method  was  used  in  conservative  Caesarean  section,  only 
three  died  ;  that  is  a  mortality  of  6.38.  If  the  operation  is  performed 
on  account  of  the  size  of  the  child,  the  longitudinal  incision  should, 
however,  be  preferred,  since  the  incision  may  be  continued  upward  as 
much  as  the  case  may  require,  while  in  the  transverse  fundal  method 
the  length  of  the  incision  is  limited  by  the  large  vessels  running  along 
the  edge  of  the  uterus. 

Anatomical  and  Physiological  Observations. — Before  being  incised 
the  uterus  is  of  purple  color,  and  the  tightly  stretched  peritoneal 
covering  reflects  light  like  a  polished  surface.  The  fundus  forms  a 
semicircular  dome,  and  the  tubes  and  ovaries  are  drawn  away  up 
in  the  abdominal  cavity  (Fig.  118,  p.  86).  During  the  incision  the 
edges  of  the  wound  retract,  so  as  to  form  a  large  gaping  opening  with 
bevelled  edges,  the  outer  muscular  layer  being  more  retracted  than  the 
inner.  At  the  bottom  of  this  gap  lies  the  ovum  as  a  transparent  gray- 
ish bag,  inside  of  which  the  foetus  is  seen  indistinctly.  When  the 
membranes  are  ruptured,  the  uterus  contracts  so  as  to  clasp  its  con- 
tents tightly.  After  the  removal  of  the  foetus  it  contracts  again,  so  as 
to  measure  only  6  or  7  inches  (15-18  centimetres)  from  os  to  fundus. 
The  more  it  contracts  the  thicker  the  wall  becomes,  and  measures  at 
last  about  1|  inches  (4  centimetres). 

After  the  uterus  is  emptied,  the  peritoneum  shrivels  up  and  lies  in 
wrinkles.  It  is  of  waxy-gray  color,  and  has  lost  all  its  former  gloss. 
In  most  cases  it  can  easily  be  lifted  up  and  pushed  to  and  fro. 

The  cut  surface  has  a  grayish-brown  color  like  half-boiled  meat^ 
and  on  it  appear  the  contracted  sinuses  as  round  cherry-colored  spots, 
I  inch  (3  millimetres)  in  diameter. 

Douglas's  pouch  is  much  shallower  than  in  tlie  unimpregnated 
condition. 

The  placenta  lies,  as  a  rule,  loose,  a  natural  consequence  of  the 
diminution  of  the  surface  to  which  it  is  attached.     The  membranes, 


QQQ  OBSTETRIC    OPERATIONS. 

on  the  contrary,  remain  fastened  to  the  inside  of  the  uterus,  and  have 
to  be  peeled  off  by  inserting  a  finger  between  them  and  the  wall.  On 
account  of  their  thinness  and  great  elasticity  they  adapt  themselves  to 
the  size  of  the  surface  on  which  they  have  grown,  which  the  placenta 
under  normal  circumstances  cannot  do.  The  separation  between  the 
uterus  and  the  membranes  takes  place  in  a  white  spongy  substance 
that  easily  breaks  under  the  advancing  fingers. 

After  the  removal  of  the  placenta  and  the  membranes,  the  inside 
of  the  uterus  is  entirely  smooth.  When  the  constrictor  is  loosened 
the  uterus  becomes  violet. 

If  no  drainage  has  been  provided  for  at  the  time  of  the  operation, 
and  the  condition  of  the  patient — high  temperature  or  collapse — points 
towards  gaping  of  the  wound  or  oozing  into  the  peritoneal  cavity,  it  is 
advisable  to  open  the  abdominal  wound  at  the  level  of  the  fundus,  and 
introduce  a  rubber  drainage-tube  or  a  gauze  or  wick  drain  behind 
the  uterus,  and  others  from  the  lower  end  of  the  incision  into  each 
side  of  the  uterovesical  excavation ;  but  this  procedure  may  disturb 
useful  adhesions  already  formed,  and  the  fluid  may  have  gravitated 
into  parts  which  are  not  reached  by  the  drains,  or  it  may  have  been 
brought  all  over  the  peritoneum  by  the  peristaltic  movement.  Too 
much  benefit  should,  therefore,  not  be  expected  from  this  tardy 
drainage. 

Time. — The  most  favorable  moment  for  performing  Caesarean  sec- 
tion is  probably  the  end  of  the  first  stage,  when  labor-pains  are  well 
developed,  the  cervix  fully  dilated,  and  the  membranes  unruptured. 
But  it  may  be  difficult  or  impossible  to  watch  the  case  until  this 
favorable  moment  arrives,  or  to  have  the  necessary  assistance  at  that 
hour,  and  experience  has  shown  that  the  operation  may  be  safely  per- 
formed several  days  before  the  expected  confinement.  The  incision 
itself  is  a  powerful  stimulus  to  uterine  contraction.  In  cases  in  which 
it  is  known  beforehand  that  Caesarean  section  is  to  be  performed,  this 
is  the  best  plan  to  follow.  It  finds  its  apphcation  with  dwarfs,  and 
other  women  in  whom  there  is  so  manifest  a  disproportion  between 
the  foetus  and  the  pelvis  that  it  is  evident  that  delivery  can  be  accom- 
plished only  by  means  of  this  operation.  It  is  also  applicable  to  mul- 
tiparas who  offer  a  history  of  the  death  of  the  foetus  in  previous  con- 
finements, on  account  of  mechanical  disproportion.  But  with  most 
primiparae  the  situation  is  different.  It  is  the  labor  itself  that  reveals 
that  the  woman  cannot  give  birth  to  her  child,  and  the  operation,  if  it 
is  advisable  at  all,  has  to  be  performed  at  the  time  when  we  come  to 
the  conclusion  that  it  is  indicated. 

Under  such  circumstances  the  patient  should  be  anaesthetized,  and 
a  thorough  examination  made,  with  the  whole  hand,  of  the  pelvis  of 
the  mother  and  the  head  of  the  foetus.     Next,  it  is  well  to  place  the 


CESAREAN    SECTION.  667 

woman  in  Walcher's  hanging  posture,  and  let  an  assistant  try  to  press 
the  head  down  into  the  brim,  which,  however,  can  be  done  only  after 
the  rupture  of  the  membranes. 

Place.— If  possible,  the  operation  should  be  performed  in  a  good 
hospital,  as  the  chances  for  aseptic  work  are  infinitely  better  there 
than  in  private  houses,  especially  the  dwellings  of  the  poor,  who  are 
much  more  likely  to  need  Caesarean  section  than  the  wealthy. 

Operator. — Who  should  perform  Caesarean  section?  Of  course 
the  best  man  available.  The  strikingly  excellent  results  that  have 
marked  the  operation  of  late  years  have  been  obtained  by  men  with 
large  experience  in  gynaecological  operations.  But  it  is  evident  that 
often  it  must  be  performed  by  a  person  with  average  surgical  skill,  and 
it  is,  therefore,  gratifying  that  it  really  is  a  simple  operation  which  has, 
in  a  rude  form,  been  done  by  persons  without  surgical  training  and 
even  by  the  patient  herself.  It  is  because  the  operator  may  not  be 
an  expert,  but  a  common  general  practitioner,  that  the  writer  has 
gone  into  so  many  details  in  describing  the  way  of  operating  and 
chosen  the  simplest  and  most  expeditious  means  of  reaching  the  goal. 
As  a  matter  of  fact,  the  operation  has  been  performed  with  a  razor,  a 
darning-needle  and  thread,  a  simphcity  which  under  circumstances 
may  be  imperative  and  may  give  relief  from  excruciating  pain  and 
save  one  or  two  lives. 

A  good  uterine  suture,  be  it  applied  in  one  way  or  another,  is  not 
only  an  immediate  protection  against  hemorrhage  and  oozing  of 
uterine  contents  into  the  peritoneal  cavity,  but  it  is  also  of  great 
value  for  the  future,  as  experience  has  shown  that  a  uterus  which  has 
been  submitted  to  Caesarean  section  is  liable  to  rupture  in  subsequent 
pregnancies,  and  the  seat  of  rupture  is  preferably  the  cicatrix  left  by 
the  operation. 

Adhesions  form  between  the  wound  in  the  anterior  wall  of  the 
uterus  and  the  abdominal  wall.  Sometimes  these  are  later  length- 
ened and  reabsorbed,  but  in  other  cases  they  become  permanent,  and 
may  have  such  dimensions  that  another  Caesarean  section  may  be  per- 
formed through  them  without  opening  the  peritoneal  cavity.  This  is 
one  reason  more  why  the  omentum  should  not  be  drawn  down 
between  the  uterus  and  the  abdominal  wall. 

The  question  arises,  whether,  in  performing  Caesarean  section,  we 
should  remove  the  appendages,  and  thereby  protect  the  woman 
against  all  the  dangers  of  subsequent  pregnancies.  It  might  be  done 
in  a  few  minutes,  but  the  writer  looks  upon  this  as  an  undesirable 
complication  of  the  operation.  After  salpingo-oophorectomy  the  pa- 
tient has  considerable  pain  for  a  whole  week,  which  probably  comes 
from  the  constriction  of  nerves  in  the  pedicles.  Two  stumps  are  left 
which  cannot  be  nourished  before  new  channels  of  blood  supply  have 


668  OBSTETRIC    OPERATIONS. 

been  formed.  The  removal  of  the  ovaries  often  has  an  undesirable 
effect  on  the  whole  organism.  Adhesions  may  form  around  the 
stumps  and  become  a  source  of  divers  troubles.  Those  to  the  bladder 
may  cause  a  frequent  desire  to  urinate.  Those  to  the  intestine  may 
provoke  pain  and  lead  to  intestinal  obstruction.  The  sexual  appetite 
may  become  uncomfortably  increased,  diminished,  or  disappear.  Many 
women  become  fat  and  dyspeptic  after  being  spayed. 

Experiments  on  animals  have  shown  that  the  removal  of  the  ova- 
ries has  a  marked  effect  on  metabolism.  The  phosphates  eliminated 
with  the  urine  and  the  carbonic  acid  contained  in  the  expired  air  di- 
minish, while  the  weight  of  the  body  increases.  In  a  large  percentage 
melancholia  has  developed  in  castrated  women.  Congestion  of  the 
head  and  thoracic  organs  and  perspiration  appear  soon  after  oopho- 
rectomy and  may  continue  for  years.  Other  disturbances  that  have 
been  noticed  are  loss  of  memory,  irritability  of  temper,  diminution  of 
the  power  of  vision,  a  more  masculine  voice,  skin  affections,  night- 
mare, and  insomnia. 

If  the  patient  shall  be  rendered  sterile  it  is  better  to  ligate  the 
tubes.  But  it  is  doubtful  whether  on  moral  grounds  it  is  justifiable  gra- 
tuitously to  deprive  a  woman  of  the  possibility  of  becoming  a  mother. 
Thus,  taking  everything  into  consideration,  I  think  it  is  better  to  Hmit 
Csesarean  section  to  the  safe  termination  of  the  present  pregnancy  and 
not  to  include  in  it  any  kind  of  measure  tending  towards  prevention  of 
future  pregnancies. 

It  is  better  not  to  fold  the  peritoneum  in  over  the  edge  of  the  inci- 
sion. The  muscular  surfaces  grow  better  together  when  it  is  not 
done  ;  but  when  the  peritoneum  is  movable  enough  to  do  so,  it  is  an 
advantage  to  unite  it  outside  of  the  incision  in  the  muscular  tissue, 
where  it  serves  as  a  curtain  and  contributes  to  the  perfect  closure  of 
the  wound  in  the  uterus. 

If  there  are  signs  of  decomposition  of  the  uterine  contents,  or 
a  diseased  endometrium,  the  uterus  should  be  mopped  and  washed 
with  an  antiseptic  solution,  and  a  rubber  drainage-tube  or  iodoform 
gauze  drain  should  be  led  from  the  uterus  to  the  vagina,  unless  the 
operator  thinks  it  is  wiser  to  remove  the  whole  organ  by  Porro's 
operation. 

Ceesarean  section  has  been  repeated  on  the  same  patient,  even 
as  often  as  four  times.  The  prognosis  for  the  repeated  operation  is 
much  better  than  in  the  first.  Sometimes  this  may  be  due  to  adhe- 
sions. Perhaps  the  peritoneum  also  becomes  less  sensitive.  But  the 
chief  cause  is  probably  to  be  sought  in  the  good  constitution  of  the  pa- 
tients :  those  who  have  gone  safely  through  the  ordeal  are  hardy 
natures  which  do  not  easily  succumb  to  influences  that  might  over- 
whelm others. 


CiESAREAN   SECTION.  669 

In  exceptional  cases  Caesarean  section  has  been  followed  by  nor- 
mal labor  in  subsequent  pregnancies,  but  there  is  great  danger  of  the 
uterus  rapturing,  either  in  the  cicatrix  or  in  another  place. 

Prognosis. — All  statistics  from  pre-antiseptic  times,  when  Caesarean 
section  was  nearly  always  a  fatal  operation,  have  now  only  historic  in- 
terest. A  competent  man,  working  under  favorable  circumstances,  on 
a  suitable  case,  need  fear  no  mortality  from  Cassarean  section.  But  this 
assertion  might  give  an  erroneous  impression  if  it  were  not  mitigated 
by  a  statement  of  the  actual  results  obtained,  as  far  as  they  are  known. 
Some  years  ago  Dr.  E.  Reynolds  collected  twenty-two  cases  operated 
on  in  Boston  by  himself  and  others,  in  which  all  mothers  and  children 
were  saved. 

But  though  some  gynaecologists  have  escaped  mortality,  others, 
not  less  experienced,  and  working  under  the  most  favorable  surround- 
ings, have  a  mortality  of  from  10  to  12  per  cent.  Uniting  the  results 
of  eleven  renowned  operators,  we  find  346  operations  with  23  deaths, 
or  Q.Q  per  cent.  But  Caesarean  section  is  not  performed  only  by  great 
experts  in  model  hospitals.  We  must  see  how  the  operation  works 
in  the  hands  of  the  profession  at  large.  According  to  Trommel's 
Annual  Report,  there  were  during  the  last  ten  years  551  cases,  of 
which  105  ended  fatally,  or  1 9  per  cent. ;  and  with  all  operations 
successful  cases  are  more  likely  to  be  put  on  record  than  those  ending 
in  death. 

In  regard  to  the  foetus  the  prognosis  is  good.  If  it  is  in  good  con- 
dition at  the  time  of  the  operation,  it  ought  to  be  brought  into  the 
world  alive,  since  the  operation  itself  does  not  contain  any  element 
of  danger  to  it.  Still,  the  same  statistics  we  just  referred  to  show 
a  fetal  mortality  in  the  hands  of  experts  in  model  hospitals  of  about 
5.7  per  cent.,  and  in  the  profession  at  large  of  7.5  per  cent. 

Relation  to  other  Operations. — Caesarean  section  enters  chiefly  in 
competition  with  symphyseotomy  and  craniotomy.  In  Caesarean  sec- 
tion the  fetal  mortality  is  only  about  one-half  of  what  it  is  in  sym- 
physeotomy— 7.5  per  cent,  compared  with  14 ;  but,  on  the  other 
hand,  the  maternal  mortality  is  considerably  larger — 19  against  11. 
In  symphyseotomy  injuries  may  occur  which  cause  a  protracted  con- 
valescence ;  but  after  Caesarean  section  there  is  often  long  suffering 
caused  by  the  adhesions,  and  the  abdominal  wound  may  lead  to 
ventral  hernia.  Symphyseotomy  gives  more  trouble  in  the  beginning, 
Caesarean  section  later  on.  Caesarean  section  is  easier  to  perform, 
and  the  after-treatment  is  very  much  simpler.  But  Ciesarcan  section 
has  an  enormous  mortality  in  unfavorable  cases, — that  is,  when  the 
labor  has  been  protracted,  the  patient  is  exhausted,  fruitless  attempts 
at  dehvery  have  been  made,  and  antiseptic  and  aseptic  precautions 
have  been  unsatisfactory ;  while  these  cases  yet  offer  a  fair  chance 


670  OBSTETRIC    OPERATIOXS. 

for  recovery  if  symphyseotomy  can  be  performed  and  is  indicated. 
Caesarean  section  is  apt  to  cause  shock,  not  so  symphyseotomy. 

We  have  said  that  with  a  true  conjugate  of  less  than  2  inches  (5 
centimetres)  Csesarean  section  should  be  performed,  wliether  the  child 
is  alive  or  dead.  If  the  true  conjugate  is  between  2  and  3  inches 
(5-7J  centimetres)  or  the  child  is  abnormally  large,  Caesarean  section 
should  be  performed  in  favorable  cases.  If  the  case  is  unfavorable, 
and  the  pehdc  dimensions  are  large  enough  for  symphyseotomy,  that 
operation  should  be  tried.  But  if  the  mother  refuses  to  be  operated 
on,  there  is  nothing  else  left  than  craniotomy. 

Caesarean  section  may  even,  like  symphyseotomy,  take  the  place  of 
difficult/orceps  or  version  operations,  as  these  have  a  much  larger  mor- 
tality for  the  foetus  and  often  cost  the  mother  her  life. 

The  surroundings,  the  possibilities  for  assistance  and  after-treat- 
ment, and  the  financial  condition  must,  independently  of  purely 
scientific  considerations,  have  considerable  influence  on  the  choice  of 
the  operation  to  be  performed.  A  man  working  in  a  good  hospital, 
with  all  desirable  assistance  at  command,  having  to  deal  with  uncon- 
taminated  cases,  may  prefer  the  comparatively  simple  operation  of 
Caesarean  section  to  symphyseotomy,  and  is  justified  in  absolutely 
refusing  to  perform  craniotomy  on  the  living  foetus.  In  private  city 
practice  we  shall  oftener  have  use  for  symphyseotomy,  but  in  country 
practice,  where  the  physician  perhaps  comes  from  a  long  distance, 
where  skilled  assistance  is  difficult  to  obtain,  where  there  are  numer- 
ous obstacles  in  the  way  of  intelligent  after-treatment,  the  practitioner 
will  probably  often  have  to  resort  to  craniotomy  even  in  cases  that 
would  be  suitable  for  Caesarean  section  or  symphyseotomy. 


CHAPTER   XV. 

UTERO-OYARIAN   AMPUTATION. 

Utero-ovarian  amputation,  or  supravaginal  amputation^  is  a 
Caesarean  section  followed  by  hystero-oophorectomy.^ 

In  contradistinction  from  the  conservative,  or  classic,  Caesarean 
section,  this  is  a  mutilating  operation,  by  which  the  patient  is  deprived 
of  her  uterus,  tubes,  and  ovaries.  When  the  Italian  obstetrician 
Porro  introduced  it  in  1876,  it  was  received  with  considerable  favor. 
Although  the  mortality  in  the  beginning  was  56  per  cent.,  that  seemed 
a  decided  progress  compared  with  Ctesarean  section  as  it  was  then, 
and  its  friends  even  looked  upon  the  spaying  of  the  patient  as  one  of 
its  advantages.     According  to  them,  a  Avoman  who  cannot  give  birth 

1  Garrrigues,  "Additional  Remarks  on  Gastro-Elj-trotomy,  with  Special  Refer- 
ence to  Porro" s  Operation,"  Amer.  Jour.  Obst.,  Jan.,  1883,  vol.  xvi.,  No.  1. 


UTERO-OVARIAN   AMPUTATION.  671 

to  a  child  has  no  right  to  have  any.  But  how  often  do  we  not  find, 
even  among  poor  people,  the  natural  desire  for  offspring  strongly 
developed  ?  How  often  is  not  a  marriage  unhappy  because  it  is  child- 
less? How  often  is  not  the  married  woman  despised  because  she 
has  no  children  ?  And  who  can  tell  of  what  he  deprives  humanity  by 
producing  artificial  sterility  ? 

Indications. — Porro's  operation  should,  therefore,  not  be  looked 
upon  as  a  substitute  for  the  conservative  Caesarean  section,  but  should 
be  reserved  for  special  cases  : 

1.  When  a  patient  has  a  myoma  that  soon  would  require  myo- 
motomy  ; 

2.  When  there  are  so  extensive  vaginal  cicatrices  that  they  form  a 
barrier  to  the  outflow  of  the  lochial  discharge  ; 

3.  When  the  uterus  is  infected,  or  has  suffered  much  by  the  vain 
efforts  of  natural  labor  or  unsuccessful  attempts  at  delivery  by  other 
methods ; 

4.  When  the  foetus  has  become  decomposed ; 

5.  When  it  is  impossible  in  any  other  way  to  control  the  hemor- 
rhage after  the  conservative  Csesarean  section  ; 

6.  Rupture  of  the  uterus,  if  abdominal  section  is  indicated,  and 
suture  of  the  uterine  wound  does  not  seem  safe. 

Some  add  osteomalacia,  but  since  it  is  only  the  ovaries  that  have 
the  disastrous  effect  on  the  bones  of  the  pelvis,  it  is  much  safer,  if  the 
uterus  is  healthy,  to  leave  it  and  only  remove  the  adnexa. 

Modus  Operandi. — The  first  step  is  to  perform  Caesarean  section. 
The  second  is  to  amputate  the  uterus  and  its  appendages.  The  stump 
may  be  treated  by  the  extra-abdominal  method  or  the  intra-abdominal, 
retroperitoneal  method. 

1,  The  Extra-abdominal  Treatment  of  the  Pedicle. — Porro'^s  Opera- 
tion.— This  is  entirely  like  the  treatment  of  the  pedicle  in  myomotomy 
by  Hegar's  method.' 

In  this  case  the  elastic  constrictor  is  intended  to  remain  until  the 
stump  falls  off,  and  is,  therefore,  fastened  in  a  permanent  and  reliable 
way.  The  rubber  tubing  is  laid  twice  around  the  cervix,  drawn  very 
tight,  and  crossed  once.  Then  the  ends  are  seized  in  front  of  the 
crossing  with  a  strong  pressure-forceps  and  tied  together  with  a 
stout  silk  ligature  behind  the  forceps.  When  this  is  tied,  the  ends  of 
the  elastic  ligature  are  pulled  out  a  little  more,  and  a  second  ligature  is 
placed  at  some  distance  behind  the  first,  and  all  the  ends  of  rubber 
and  silk  ligatures  are  cut  short.  But  in  order  to  avoid  asphyxia  the 
foetus  should  first  be  helped  out  before  the  tubing  is  secured  in  such 
an  elaborate  way.  If  it  is  dead,  it  is  better  not  to  open  the  uterus 
at  all,  in  order  to  avoid  infection  of  the  peritoneal  cavity. 
^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  619. 


672  OBSTETRIC    OPERATIONS. 

Another  way  of  securing  the  tubing  is  to  have  an  assistant  lay  the 
silk  ligature  on  the  top  of  the  first  half-hitch  of  the  knot,  at  right 
angles  to  the  elastic  ligature  ;  next,  to  tie  this  with  a  second  hitch ; 
and,  finally,  to  tie  the  silk  ligature  across  the  second  crossing  of  the 
elastic  ligature. 

As  soon  as  the  uterus  is  emptied,  it  is  well,  in  order  still  more 
effectively  to  guard  against  contamination,  to  pack  its  cavity  with 
sterilized  gauze.  The  manipulation  of  this  organ  is  much  facilitated 
by  fastening  a  traction-forceps  in  each  edge  of  the  incision. 

Next,  the  uterus  and  the  broad  ligaments  with  the  adnexa  are  cut 
off  from  one  and  a  half  to  two  inches  (4-5  centimetres)  above  the 
elastic  ligature.  The  cervical  canal  is  disinfected  by  touching  it  with 
undiluted  carbolic  acid.  All  arteries  seen  on  the  cut  surface,  especially 
the  uterine,  the  ovarian,  and  the  azygos,  should  be  seized  and  tied 
separately,  and  the  peritoneal  covering  of  the  stump  stitched  with  a 
fine,  curved,  round  needle  and  a  continuous  catgut  suture  to  the  peri- 
toneum near  the  lower  end  of  the  abdominal  incision,  under  the  hga- 
ture,  so  as  to  close  the  peritoneal  cavity.  The  remaining  peritoneal 
edges  are  stitched  together,  and  the  abdominal  wound  is  closed  as  in 
other  laparotomies,^  leaving  a  circular  furrow,  formed  by  the  receding 
muscular,  fascial,  adipose,  and  cutaneous- layers  of  the  abdominal  wall. 

In  order  to  avoid  the  dangers  of  infection  as  much  as  possible, 
the  amputation  of  the  uterus  may  to  advantage  be  postponed  until 
the  peritoneum  has  been  stitched  to  the  stump  and  its  borders 
united  above  it. 

The  stump  is  transfixed  with  a  pair  of  steel  pins  crossing  one 
another  above  the  ligature,  which  they  prevent  from  slipping,  and  at 
the  same  time  they  avert  drawing-in  of  the  stump  into  the  abdominal 
cavity.  In  order  to  preclude  pressure  against  the  abdominal  wall,  a 
little  gauze  is  put  under  the  needles.  The  cut  surface,  as  well  as  the 
surrounding  furrow,  is  covered  with  a  mixture  of  3  parts  of  tannin 
with  1  part  of  salicylic  acid.  Finally,  the  wound  is  dressed  as  after 
conservative  Csesarean  section  and  other  laparotomies. 

The  stump  falls  off  after  fifteen  to  twenty  days,  leaving  a  deep, 
funnel-shaped  depression,  the  necrosis  extending  beyond  the  elastic 
ligature.  This  surface  is  dressed  daily  with  iodoform  gauze  until  it 
is  healed. 

In  leaving  the  above-described  furrow  free  between  the  stump  and 
the  abdominal  wah,  except  the  peritoneum,  a  great  source  of  infec- 
tion and  death  has  been  eliminated ;  but,  on  the  other  hand,  a  weak 
point  is  left  in  the  abdominal  wall,  and  it  is  necessary  for  the  patient 
to  wear  an  abdominal  supporter. 

If  the  accoucheur  does  not  feel  competent  to  do  the  peritoneal 
^  Garrigues,  Diseases  of  Women,  third  ed.,  p.  649. 


UTERO-OVARIAN   AMPUTATION.  673 

suturing,  or  if  the  patient's  condition  imposes  the  utmost  speed,  the 
abdominal  wound  may  simply  be  closed  around  the  stump  with  in- 
terrupted sutures,  and  then  the  whole  operation  is  simpler  and  more 
expeditious  than  conservative  Caesarean  section. 

2.  The  Intra-abdominal,  Retroperitoneal  Method. — The  extra-abdom- 
inal treatment  is  the  original  Porro  operation,  and  recommends 
itself  as  the  simplest,  most  expeditious,  and  safest,  but  the  intra- 
abdominal method  has  the  great  advantage  that  the  abdominal  wound 
is  entirely  closed,  and  no  tissue  undergoes  necrosis.  The  procedure  is 
exactly  the  same  as  in  supravaginal  amputation  for  myoma,^  but  on 
account  of  the  size  of  the  blood-vessels  during  pregnancy,  haemostasis 
is  more  difficult. 

After  having  delivered  the  child  and  before  excision  of  the  womb, 
a  flap  of  peritoneum  is  dissected  off  in  front  and  behind  from  the 
uterus.  When  the  uterus  has  been  cut  off  and  the  arteries  on  the 
cut  surface  tied  separately,  the  lips  of  the  cervix  are  stitched  together 
and  then  the  two  peritoneal  edges  are  united  by  a  running  symperi- 
toneal  suture  along  the  whole  wound.  Next  the  elastic  constrictor  is 
removed,  the  pedicle  dropped  into  the  abdomen,  and  the  incision  in 
the  abdomen  closed. 

If  the  uterus  is  infected,  the  extra-abdominal  treatment  is  the 
better  one,  but  with  an  aseptic  uterus  the  intra-abdominal  retroperi- 
toneal method  is  preferable. 

Utero-ovarian  amputation  may  be  performed  at  the  time  conven- 
ient for  the  operator.  Everything  needed  can  be  prepared  at  leisure, 
and  the  operation  can  be  done  before  the  patient  has  lost  any  of  her 
strength  by  ineffectual  efforts  at  delivery  through  the  natural  passages. 
But  often  the  obstetrician  does  not  see  the  patient  until  after  she  is 
infected,  and  an  immediate  operation  is  her  only  chance  of  recovery. 

Prognosis. — Not  long  ago  utero-ovarian  amputation  had  a  maternal 
mortality  of  37  per  cent.,  but  it  must  be  remembered  that  the  opera- 
tion is  frequently  chosen  because  the  case  is  too  bad  for  the  conserva- 
tive Caesarean  section.  During  the  last  few  years  there  have  been 
performed  111  Porro  operations  by  great  operators  with  a  loss  of  only 
11  women, — that  is,  about  10  per  cent. 

Utero-ovarian  amputation  causes  still  more  shock  than  the  conser- 
vative Caesarean  section.  The  haemostasis  often  has  proved  very  diffi- 
cult. There  is  great  danger  of  peritonitis  and  septicaemia.  Other  mis- 
haps met  with  have  been  non-union  of  the  pedicle,  tetanus,  pulmona^-y 
oedema,  hyperpyrexia,  heart-clot  starting  from  a  femoral  thrombus,  etc. 

The  infantile  mortality  varies  much  with  the  mother's  condition, 
but  it  is  always  great.     Modern  statisticians  give  it  as  16,  21,  or  24. 
per  cent. 

^  Garrigues,  Diseases  of  Women,  third  cd.,  p.  518. 
43 


674  OBSTETRIC    OPERATIONS. 

Apart  from  the  immediate  result,  the  extirpation  of  the  internal 
genitals  has  often,  as  stated  above  (p.  668),  a  bad  influence  on  the 
general  health. 

CHAPTER   XVI. 
PANHYSTERECTOMY. 

Some  obstetricians  have  gone  one  step  farther  and  extirpated  the 
whole  uterus,  inclusive  of  the  cervical  stump,  which  complicates  the 
operation  still  more. 

§  1.  Abdominal  Hysterectomy. — Indications. — The  indications 
are  chiefly  the  same  as  for  supravaginal  amputation  :  (1)  Death  of  the 
foetus  with  infection  of  the  uterus  ;  (2)  vaginal  cicatrices  that  prevent 
the  free  discharge  of  the  lochia ;  (3)  a  myoma  of  the  cervix  that  can- 
not be  enucleated  at  the  time  of  the  operation ;  (4)  rupture  of  the 
uterus  under  the  above-mentioned  conditions  (see  pp.  531,  671). 

If  there  is  an  inoperable  carcinoma  of  the  cervix,  it  is  better  to 
perform  supravaginal  amputation  and  leave  the  neoplasm  alone,  or  to 
curette  and  cauterize  the  cervix  and  deliver  by  Csesarean  section. 

The  total  extirpation  of  the  uterus  offers  the  advantage  over  any 
kind  of  utero-ovarian  amputation  that  the  danger  of  infection  is  mini- 
mized, and,  compared  with  the  extraperitoneal  method  of  the  treat- 
ment of  the  stump  in  Porro's  operation,  there  is  less  danger  of 
intestinal  obstruction,  a  shorter  convalescence,  and  less  danger  of 
consecutive  ventral  hernia.  But  in  spite  of  these  great  benefits  the 
writer  hesitates  to  recommend  the  operation  to  the  profession  at  large. 
Obstetric  operations  ought  to  be  as  simple  as  possible.  They  obtrude 
themselves  on  the  general  practitioner  when  they  are  not  expected, 
and  he  has  often  to  act  under  highly  unfavorable  surroundings  and 
with  deficient  assistance.  Every  practitioner  who  can  amputate  an 
arm  or  a  leg  can  perform  the  conservative  Caesarean  section.  Porro's 
operation  in  the  strict  sense  of  the  word — utero-ovarian  amputation 
with  extra-abdominal  treatment  of  the  stump — is  even  simpler.  But 
when  we  come  to  the  intra-abdominal  treatment  of  the  stump,  we 
enter  on  the  domain  of  the  highest  gynaecological  work,  and  this  is 
still  more  the  case  with  the  total  oophorohysterectomy. 

Ilodus  Operandi. — The  vagina  is  packed  with  gauze  in  order  to 
lift  it  and  mark  the  line  of  demarkation  between  it  and  the  cervix. 
The  abdominal  incision  is  made  long  enough  to  allow  the  operator 
to  lift  the  uterus  out  with  its  contents.  The  elastic  constrictor  is  put 
around  the  cervix,  and  Caesarean  section  is  performed  as  described 
above,  but  the  uterus  is  only  closed  with  deep  sutures  in  order  to 
prevent  hemorrhage  from  the  wound  during  the  following  extirpation 
of  the  uterus. 


PANHYSTERECTOMY.  675 

The  patient  is  placed  in  the  elevated-pelvis  position.  The  opera- 
tor stands  on  her  left  side  and  his  assistant  opposite  to  him.  The 
top  of  the  uterus  is  seized  with  a  strong  traction-forceps  and  drawn 
by  the  assistant  over  to  his  side.  The  left  infundibulopelvic  ligament 
containing  the  ovarian  vessels  is  tied,  a  clamp  put  inside  of  the  liga- 
ture, and  the  ligament  cut.  Next,  the  round  ligament  with  the  funicular 
artery  is  tied,  clamped,  and  the  first  incision  extended  down  towards 
the  cervix  in  the  neighborhood  of  the  uterine  artery.  Then  the  left 
uterine  artery  is  tied,  clamped,- and  cut.  An  incision  is  carried  from 
this  point  transversely  over  to  the  opposite  point  on  the  other  side,  but 
only  through  the  peritoneum.  This  flap  containing  the  bladder  is  sep- 
arated with  closed  blunt  scissors  from  the  uterus.  A  similar  smaller 
flap  of  peritoneum  is  separated  from  the  posterior  surface  of  the 
uterus.  After  that  the  vagina  is  opened  just  under  the  cervix  in 
the  left  side  vault,  and  the  opening  extended  with  scissors  all  around, 
and  as  soon  as  there  is  room  the  cervix  is  seized  through  the  incision 
and  pulled  upward  and  over  to  the  right.  Next,  the  right  uterine 
artery  is  tied  and  cut,  then  the  right  round  ligament,  and  finally  the 
right  infundibulopelvic  ligament,  so  that  the  whole  uterus  and  its  ap- 
pendages are  removed  in  one  piece. 

If  any  other  artery  than  the  six  mentioned  bleeds,  it  is  provi- 
sionally seized  with  a  clamp  and  tied  when  the  uterus  is  out  of  the 
way. 

The  cut  edges  of  the  broad  ligaments  are  brought  together  with  a 
running  catgut  suture.  When  the  vagina  is  reached,  this  is  pulled  up 
and  included  in  the  peritoneal  suture,  in  order  to  prevent  future  pro- 
lapse. The  opening  in  the  vagina  itself  may  be  closed,  but  if  it  is  a 
case  of  sepsis  it  is  better  to  leave  it  open  and  put  a  drain  of  iodo- 
form gauze  into  it  from  the  peritoneal  cavity,  and  I  am  inclined  to 
think  that  even  in  aseptic  cases  it  is  better  to  drain,  as  the  drainage 
replaces  the  natural  discharge  from  the  uterus. 

If  the  foetus  is  dead  and  the  case  septic,  it  is  best  not  to  open 
the  uterus  at  all,  but  to  extirpate  it  as  we  would  do  if  we  had  to 
deal  with  a  myomatous  uterus.  Finally,  the  abdominal  wound  is 
closed  as  after  other  laparotomies. 

Total  abdominal  extirpation  can  be  done  and  has  been  done  during 
pregnancy  and  labor  with  success,  but  I  doubt  that  others  than  the 
most  expert,  dexterous,  and  rapid  operators  will  do  well  in  adopting 
panhysterectomy  in  obstetric  practice. 

§  2.  Vaginal  Hysterectomy. — Total  hysterectomy  may  also  be 
performed  from  the  vagina.  As  a  rule,  we  may  say  that  this  method 
is  preferable  in  septic  abortion  cases,  while  in  deliveries  at  or  near 
term  the  abdominal  operation  is  generally  to  be  preferred. 

In  this  respect  carcinoma  of  the  cervix  forms,  however,  an  ex- 


676  OBSTETRIC    OPERATIONS. 

ception.  If  the  carcinoma  is  so  much  advanced  as  not  to  be  opera- 
ble, we  have  said  above  that  the  best  is  to  perform,  supravaginal 
amputation  and  leave  tlie  carcinoma  alone  or  to  curette  and  cauterize 
the  cervix  and  deliver  the  patient  by  Caesarean  section. 

But  if  the  cancer  is  operable,  it  has  of  late  been  recommended 
to  deliver  through  the  vagina  and  then  extirpate  the  uterus  by  the 
same  v^ay  (p.  295),  and  this  has  been  done  both  during  advanced 
pregnancy  and  during  labor. 

This  operation  is  called  vaginal  Ccesarean  section,  and  is  thus  de^ 
scribed  by  its  inventor,  Diihrssen,  of  Berlin. 

Modus  Operandi. — The  cervix  is  curetted  and  cauterized.  The 
parametria  are  circumvented.  The  vagina  is  separated  from  the  uterus, 
and  if  necessary  incised  longitudinally.  The  cervix  is  severed  above 
the  carcinoma,  while  the  uterus  is  being  pulled  down  all  the  time.  If 
necessary,  bleeding  points  on  the  uterus  are  secured  by  circumvention. 
Then  the  anterior  and  posterior  uterine  walls  are  rapidly  incised  in  the 
median  line  until  the  foetus  can  easily  be  extracted.  Next,  the  pla- 
centa is  removed,  and  the  incisions  in  the  uterus  are  continued  till 
both  the  anterior  and  the  posterior  cul-de-sac  are  opened.  The  liga- 
ments may  be  clamped  or  tied  from  above  downward.  The  stumps 
may  be  pulled  down  into  the  vagina  and  the  opening  in  the  vagina 
closed  with  sutures. 

The  advantage  claimed  for  this  operation  is  that  by  it  the  pregnant 
uterus  can  be  emptied  at  any  time  during  pregnancy  or  labor, 

Schauta,  who  has  performed  the  operation,  says  there  was  "  hor- 
rible bleeding"  in  cutting  the  uterus.  He  advises,  therefore,  only  to 
incise  the  anterior  wall  and  pull  the  edges  well  down,  which  arrests 
hemorrhage.  He  advises  furthermore  to  leave  the  placenta  in  the 
uterus.     Its  loosening  takes  time,  and  it  is  not  in  the  way. 

Chroback  found  it  difficult  to  see  the  line  of  demarcation  between 
the  vagina  and  cervix.  He  says  it  is  important  to  separate  the  blad- 
der well,  also  laterally,  and  make  a  large  opening  in  the  peritoneum. 
The  uterine  tissue  being  so  soft  and  friable,  the  traction-forceps  are 
apt  to  tear  out,  especially  the  common  bullet-forceps.  The  ligatures 
should  be  rather  thick,  in  order  not  to  cut,  and  while  they  are  being 
tightened,  traction  from  below  must  be  slackened. 

The  child  has  been  delivered  by  the  high  forceps  or  by  version. 

This  operation  is  yet  too  new  to  form  a  definite  opinion  about  its 
value,  and  it  need  hardly  be  added  that  it  is  only  an  operation  for 
expert  gynaecologists. 

In  cases  of  sepsis  after  abortion,  the  uterus  may  be  removed 
through  the  vagina,  just  as  any  non-pregnant  uterus  with  a  fibroma 
or  beginning  cancer,^ 

^  Garrigues,  Diseases  of  Women,  third  ed. ,  p.  510  et  seq. 


EMBRYOTOMY.  677 

CHAPTER    XVII. 
EMBRYOTOMY. 

Embryotomy  is  a  general  term,  comprising  all  the  operations  by 
which  the  body  of  the  fetus  is  diminished  in  order  to  deliver  it  from 
the  maternal  body,  namely,  craniotomy^  decajntatlon,  evisceration,  brachi- 
otomy,  and  cleidoiomy. 

§  1,  Craniotomy. — Craniotomy,  or  cephalotomy,  is  an  operation 
by  which  the  size  of  the  fetal  head  is  diminished  ;  and,  as  a  rule,  the 
foetus  is  thereafter  extracted. 

It  is  one  of  the  oldest  obstetric  operations,  frequently  resorted  to 
by  the  old  Greeks  and  Romans. 

Indications. — 1.  Dead  Foetus. — If  the  foetus  is  dead  and  there  is  an 
obstruction  in  the  way  of  its  progress,  or  the  mother's  condition  makes 
a  speedy  delivery  desirable  ;  and  if,  on  the  other  hand,  there  is  no 
absolute  indication  for  Caesarean  section,  the  fetal  head  should,  in  the 
interest  of  the  mother,  be  diminished.  Great  care  must,  however,  be 
taken  not  to  make  a  mistake  in  declaring  the  foetus  dead.  Fetal  heart- 
sounds  may  temporarily  be  inaudible  ;  a  discharge  of  meconium  shows 
only  that  the  child  is  in  a  dangerous  condition ;  a  pulseless,  prolapsed 
cord  may  belong  to  a  twin.  It  is  only  by  following  the  case  for  a 
longer  period  that  the  accoucheur  can  satisfy  himself  that  the  foetus  is 
dead. 

2.  Living  Foetus. — With  the  great  advancements  made  in  obstetrics 
in  modern  times  through  symphyseotomy  and  Caesarean  section,  there 
is  a  growing  indisposition  to  kill  the  child  in  order  to  save  the  mother, 
and  we  have  seen  above  that  the  Roman  Catholic  Church  does  not 
allow  its  adherents  to  have  this  operation  performed.  To  wait  till 
the  child  dies  and  then  mutilate  it,  is  not  only  sophistry,  but  often 
leads  to  the  death  of  the  mother  through  rupture  of  the  uterus,  ex- 
haustion, or  infection.  The  writer  is  of  the  opinion  that  no  chief  of 
a  public  lying-in  hospital  should  be  compelled  to  kill  a  living  child  in 
its  mother's  uterus,  as  long  as  there  is  a  fair  chance  of  saving  both 
by  means  of  symphyseotomy  or  Caesarean  section.  But  in  private 
practice  the  accoucheur  will  in  most  cases  be  required  to  do  so,  if 
thereby  the  mother  can  be  saved  ;  and  especially  in  country  practice, 
where  the  doctor  comes  from  far  away  and  has  many  other  patients 
to  attend  to,  he  often  will  be  forced  to  sacrifice  the  foetus  ;  but  as  far  as 
possilDle  this  should  not  be  done  without  a  consultation  with  another 
practitioner. 

The  operation  is  indicated  :  1 .  In  contracted  pelvis  with  a  con- 
jugate between  2  and  3  inches  (5-7|  centimetres).  2.  With  too  large 
a  child.     3.  With  tumors,  cicatrices,  or  other  obstructions  in  the  soft 


678 


OBSTETRIC    OPERATIONS. 


part  of  the  genital  tract,  if  delivery  is  necessary  in  order  to  save  the 
mother  from  actual  danger,  threatening  her  life,  and  it  cannot  be  ac- 
complished in  a  conservative  way.  As  a  rule,  craniotomy  will  not  be 
resorted  to  under  this  indication  until  delivery  with  forceps  or  version 
has  proved  impossible.  As  to  version  it  should,  how^ever,  be  remem- 
bered that  the  greatest  danger  threatening  the  mother  is  rupture  of 
the  uterus,  and  there  may  be  such  a  distention  of  the  lower  uterine 
segment  and  the  cervix  that  the  very  introduction  of  the  hand  would 
produce  the  rupture. 

Conditions. — In  order  to  follow  the  indication,  certain  conditions 
must  be  present.  1.  The  pelvis  must  be  large  enough  to  let  the  dimin- 
ished head  pass.  2.  The  os  must  be  so  dilated  that  the" necessary  in- 
struments can  be  applied  to  the  head  without  injury  to  the  mother; 
and  if  extraction  is  to  follow  immediately,  the  cervix  must  be  so  dilated 
that  this  can  be  done  safely.     3.  The  head  must  be  within  reach. 

In  hydrocephalus  craniotomy  is  contraindicated.  There  the  head 
is  diminished  by  puncturing  it  with  a  trocar  through  a  fontanelle  or 
suture.  When  the  serum  is  let  out  the  head  may  collapse  sufficiently 
for  the  child  to  be  born,  and  craniotomy  should  be  abstained  from, 
as  such  children  whose  heads  were  merely  punctured  have  been  born 
alive  and  lived  several  days,  which  may  have  important  legal  conse- 
quences. 

With  after-coming  head  it  is  never  necessary  to  use  craniotomy  on 
the  living,  because  the  child  will  be  dead  within  a  few  minutes. 

Craniotomy  is  a  general  term  that  includes  several  operations  :  per- 
foration, cranioclasis,  cephalotripsy,  removal  of  the  cranial  vault,  and 
basilysis. 

Perforation. — The  patient  is  anaBsthetized  and  placed  across  the  bed 
or  on  a  table.  The  pubes  are  shaved  off,  or  at  least  cut  short,  and  the 
vagina  is  disinfected.  The  four  fingers  of  the  left  hand  are  introduced 
into  the  vagina,  so  as  to  protect  it  on  all  sides  against  injury  from  the 
perforator.     An  assistant  presses  the  head  well  down  on  the  brim, 


Fig.  475. 


Naegele's  perforator. 


while  the  operator  perforates  the  skull.  Two  kinds  of  perforators  are 
needed, — Naegele's  scissors-shaped  perforator,  opening  outward  (Fig. 
475),  and  Thomas's  knife  concealed  in  a  screw-pointed  tube.  Naegele's 
instrument  can  on  the  head  be  used  for  perforation  only  at  a  fonta- 
nelle or  a  suture.    It  is  introduced  closed  and  pushed  in  to  the  wings. 


EMBRYOTOMY. 


679 


Then  the  bar  at  the  posterior  end  is  cast  loose,  and  the  instrument 
opened  to  its  fuh  width,  cutting  in  both  directions.  Next,  it  is  closed 
again  and  reintroduced  at  right  angles  to  the  first  cut,  and  made  to  cut 
as  before.  This  instrument  is  of  particular  value  with  after-coming 
head,  when  perforation  is  made  through  the  vertebral  column,  since 
it  can  be  used  for  cutting  the  skin  and  muscles,  as  well  as  bones  and 
membranes. 

For  all  other  purposes  Thomas's  perforator  is  far  preferable  (Fig. 
476).     With  it  the  operator  is  entirely  independent  of  fontanelles  and 

Fig.  476. 


Thomas's  perforator. 


sutures.  Whatever  portion  of  the  head  is  most  accessible  is  perforated 
by  screwing  the  instrument  into  the  skull  and  pushing  it  to  the  pro- 
truding rim.  By  pressure  a  strong  knife  is  made  to  project  sidewise 
from  the  tube  and  cut  whatever  is  in  its  way.  By  repeating  the  cut- 
ting in  different  directions  a  crucial  incision  is  made  through  the  skull. 

As  the  head,  as  a  rule,  slides  forward,  the  handle  of  the  perforator 
should  be  well  depressed  towards  the  perineum  and  the  instrument 
inserted  behind  the  symphysis. 

Whether  we  use  one  instrument  or  the  other,  when  first  the 
crucial  incision  is  made,  the  instrument  should  be  closed  and  moved 
in  all  directions  inside  of  the  cranium,  so  as  to  break  up  the  brain.  If 
the  foetus  is  alive,  particular  pains  should  be  taken  to  destroy  the 
medulla,  which  causes  instant  death  and  avoids  the  harrowing  specta- 
cle of  the  child  being  born  mutilated  and  still  alive. 

It  is  not  necessary  to  wash  out  the  cerebral  substance.  I  think 
even  it  is  better  not  to  do  so,  because  in  most  cases  the  perforated 
head  will  be  extracted  with  an  obstetrical  forceps,  and  in  order  that 
the  instrument  may  get  a  grip  on  the  head  this  ought  not  to  be  too 
small  and  flaccid. 

If  the  operator  prefers  to  turn  and  extract  manually,  it  may  be 
well  to  empty  the  skull,  which  can  easily  be  done  after  it  is  broken  up, 
by  introducing  a  metal  tube  connected  with  a  fountain  syringe.  Great 
care  should  be  taken  to  cover  spicute  well  with  the  scalp,  so  as  to 
prevent  them  from  wounding  the  inside  of  the  womb. 

If  the  OS  is  not  sufficiently  dilated  at  the  time  of  the  perforation,  it 


680 


OBSTETRIC    OPERATIONS. 


is  better  to  leave  the  case  to  nature  or  dilate  the  os  artificially  before 
extraction. 

The  after-coming  head  may  be  perforated  through  the  occipital 
bone  or  one  of  the  lower  side  fontanelles,  behind  the  ear,  through  the 
mouth,  or  through  the  vertebral  column.  For  this  last  purpose,  a 
longitudinal  incision  is  made  in  the  median  line  of  the  neck  or  back, 
some  arches  of  vertebrae  are  cut,  and  the  perforator  is  pushed  through 
the  foramen  magnum.  When  the  brain  is  broken  up  it  may  be 
washed  out  as  stated  above. 

As  a  rule,  perforation  is  followed  up  by  extraction.  We  have 
said  that  this  may  sometimes  be  done  with  forceps  or  by  version,  but 
if  there  is  a  considerable  obstruction,  other  means  will  be  required. 

Cranioclasis. — The  craniodast  was  invented  by  Sir  J.  Y.  Simpson 
and  much  improved  by  Carl  Braun.  Simpson's  instrument  is  smaller 
and  was  designed  both  to  extract  the  head  and  to  break  off  bones  from 
the  skull  (Fig.  477).     Braun  has  retained  the  principle  of  an  internal 

Fig.  477. 


J.  Y.  Simpson's  craniodast. 


and  an  external  blade,  but  has  made  the  instrument  larger  and  more 
powerful  and  added  a  compressing  screw  at  the  handles  (Fig.  478). 


Fig.  478. 


Braun's  craniodast. 


Simpson's  instrument  is  rarely  used,  as  its  name  w^ould  indicate, 
to  break  up  the  skull,  and  Braun's  not  at  all.     It  is  a  most  excellent 


EMBRYOTOMY. 


681 


instrument  of  extraction  after  perforation.  It  consists  of  two  blades, 
locked  like  those  of  a  forceps.  Both  have  a  small  curve  in  the  same 
direction,  so  that  one  fits  into  the  other  ;  the  inner  is  solid,  the  outer 
fenestrated,  and  both  are  serrated,  so  that  both  working  together  have 
a  good  grip  on  the  intermediate  bone  and  scalp.  The  solid  blade  is 
passed  through  the  opening  made  with  the  perforator,  and  the  fenes- 
trated between  the  fetal  scalp  and  the  uterus.  If  the  piece  of  bone 
first  seized  breaks  off,  the  instrument  is  reapplied  on  another  part  of 
the  cranial  vault.  The  great  value  of  the  cranioclast  as  compared 
with  the  cephalotribe,  which  is  an  older  instrument,  is  that  it  is  easier 
to  apply,  takes  less  room  in  the  pelvis,  is  better  fit  for  traction,  and 
draws  the  head  out  into  a  long  body  instead  of  making  it  protrude 
more  in  one  place  while  diminishing  it  in  another.  The  author  has 
sometimes  combined  the  cranioclast  of  Simpson  with  the  forceps,  and 
was  well  satisfied  with  the  result. 

Cephalotripsy. — The  cephalotribe  is  a  powerful,  narrow-bladed 
forceps,  with  slight  pelvic  curvature  and  still  less  cephalic  curvature. 
It  may  have  solid  or  fenestrated  blades,  which  are  brought  together 
with  a  screw.  It  is  meant  for  crushing  and  extracting  the  head.  One 
of  the  best  instruments  of  this  kind  is  that  of  Braxton  Hicks  (Fig.  479). 

Fig.  479. 


Braxton  Hicks's  cephalotribe. 


The  blades  are  appHed  on  two  opposite  points  of  the  head,  under 
the  guidance  of  the  four  fingers,  great  care  being  taken  not  to  injure 
the  cervix.  The  instrument  is  locked  like  a  forceps  and  screwed 
together  slowly,  as  otherwise  the  head  might  slip  away  from  its  grasp. 
It  often  is  necessary  to  reapply  it,  which  may  be  difficult  when  a 
furrow  is  made  by  the  first  application.  It  is  recommended  to  allow 
labor-pains  to  work  in  the  intervals,  and  to  let  an  hour  or  even  two, 
three,  or  four  hours  elapse  before  the  instrument  is  reapplied.  If  the 
cephalotribe  is  used  for  extraction,  the  accoucheur  should  follow  every 


682 


OBSTETRIC    OPERATIONS. 


rotation  observed  on  the  head.  The  body  of  the  foetus  is  usually  so 
soft  that  when  the  head  is  extracted  it  does  not  offer  any  serious 
obstacle  to  delivery.  If  it  exceptionally  does,  the  cephalotribe  may 
be  applied  to  it.  Since  the  cranioclast  has  become  popular  in  Great 
Britain  and  Germany,  some  obstetricians  are  inclined  to  do  away  with 
the  cephalotribe,  which  is  a  French  instrument. 

Removal  of  the  Cranial  Vault. — When  the  pelvis  is  very  narrow 
it  has  been  found  expedient  to  break  off  piecemeal  the  whole  bony 
vault  of  the  cranium.  This  is  done  with  instruments  called  crani- 
otomy-forceps, — for  instance,  that  of  Thomas  (Fig.  480). 

They  are  strong  bone-forceps,  which  are  introduced  with  one  jaw 
inside  of  the  bone  and  the  other  between  the  bone  and  the  scalp. 
By  a  sudden  wrench  of  the  wrist,  as  large  a  piece  as  possible  is 
broken  off,  great  care  being  taken  to  prevent  it  from  wounding  the 


Fig.  480. 


GiTIEMFKNNa-QQ 

Thomas's  crauiotomy-forceps. 


soft  parts  of  the  genital  canal.  In  this  way  the  whole  vault  of  the 
cranium  may  be  removed,  and  it  is  then  recommended  to  turn  the 
face  downward,  which  probably  will  be  feasible  by  means  of  the 
cranioclast  or  the  craniotomy-f creeps.  The  distance  from  the  orbit 
to  the  chin  of  the  foetus  is  only  about  one  inch.  If  then  there  is  a 
space  of  3  inches  (7J  centimetres)  from  side  to  side,  the  remainder  of 
the  head  may  be  pulled  out. 

Basilysis. — Perforation  attacks  only  the  cranial  vault,  and  the 
cephalotribe  may  not  succeed  in  crushing  the  much  stronger  bones 
forming  the  base  of  the  cranium.  Special  instruments  have  there- 
fore been  devised  for  breaking  this  part  up.  In  France  they  use 
Tarnier's  basiotribe  (Fig.  481). 

The  basiotribe  consists  of  three  parts, — 1,  a  straight  perforator 
with  screw-point  that  is  to  pass  through  the  vault  and  into  the  base  ; 
2,  a  blade  to  be  apphed  outside  the  head  and  jointed  to  the  perfo- 
rator, so  as  to  make  of  it  a  modified  cranioclast ;  3,  a  second  blade 
to  be  applied  when  necessary  to  the  side  of  the  head  opposite  to  that 
which  was  caught  by  the  first,  so  as  to  make  of  the  instrument  a 
modified  cephalotribe. 


EMBRYOTOMY. 


683 


Another  instrument,  the  basilyst,  has  been  invented  by  Prof.  A.  R. 
Simpson,  of  Edinburgh  (Fig.  482).  It  consists  of,  1,  a  perforator  with 
screw-point,  which  can  be  opened  in  two  halves  by  means  of  a  screw- 


FiG.  481. 


Tarnier's  basiotribe. 
Fig.  482. 


A.  ,R.  Simpson's  basilyst.     .1,  perforator  ;  /.',  oiitrr  liladc. 

bar ;  and  2,  an  outer  solid,  serrated  blade,  whicii  articulates  with  the 
first,  as  in  a  cranioclast.  ..  Tiie  same  screw  which  serves  to  open  the 
inner  stem,  being  turned  the  other  way,  presses  the   outer   blade 


684  OBSTETRIC    OPERATIONS. 

against  the  perforator.  This  would  seem  to  be  an  excellent  instru- 
ment. The  perforator  is  bored  through  the  vault  and  the  base,  which 
are  broken  up  by  separating  the  component  parts  of  the  perforator, 
and  then  the  outer  blade  is  introduced  and  jointed  with  the  former, 
constituting  a  cranioclast. 

All  these  operations  may  be  facilitated  by  turning  the  patient  9n 
the  left  side  and  introducing  a  large  Sims  speculum,  which  not  only 
allows  us  to  see  wdiat  we  are  doing,  but  also  offers  a  perfect  protection 
for  the  posterior  wall  of  the  vagina  and  the  vulva. 

The  crotchet  is  a  sharp  steel  hook  with  a  curved  shank  and  a 
handle  (Fig.  483).     It  used  to  be  hooked  on  to  the  inside  of  the  base 

Fig.  483. 


Crochet. 

of  the  cranium  ;  but,  if  it  loses  its  grip  while  forcible  traction  is  being 
made,  it  is  so  dangerous  both  for  patient  and  doctor  that  with  good 
reason  it  has  been  discarded  nearly  everywhere. 

Prognosis. — With  our  present  antiseptic  measures  and  with  average 
skill  on  the  part  of  the  obstetrician,  a  simple  perforation  should  have 
no  maternal  mortality.  Still,  at  a  not  very  remote  date,  Wyder  ^  col- 
lected 168  miscellaneous  cases,  with  a  mortality  of  14  per  cent.,  and 
in  the  clinic  of  Halle  and  the  policHnics  of  Berlin  and  Leipsic,  where 
it  is  to  be  presumed  the  operation  was  well  performed,  there  were 
215  cases,  with  a  mortality  of  12,  or  5.6  per  cent.  The  trouble  is 
that  these  cases  frequently  have  been  in  the  hands  of  ignorant  mid- 
wives  and  inferior  physicians,  who  delay  asking  for  help  in  time,  and 
thus  expose  the  woman  to  exhaustion  and  infection. 

The  cephalotribe  is  a  formidable  instrument,  which  besides  crush- 
ing the  fcetus  is  apt  to  inflict  injury  on  the  mother.  Good  reports 
come  of  the  results  obtained  with  the  basiotribe  ;  and  the  basilyst 
has  the  great  advantage  over  it  of  having  only  one  external  blade. 
It  is  really  only  a  vastly  improved  cranioclast,  an  instrument  that 
almost  has  driven  the  cephalotribe  from  the  field. 

Operations  by  which  the  whole  cranial  vault  is  removed  are 
necessarily  dangerous,  and  hardly  to  be  undertaken  by  anybody  who 
is  not  an  expert.  Fortunately,  cases  demanding  such  a  treatment 
are  exceedingly  rare,  and,  in  the  writer's  opinion,  the  prospects  for 
the  patient  would  be  better  if  Caesarean  section  were  performed,  not 
to  speak  of  the  possibility  of  saving  the  child's  life. 

1  Wyder,  Archiv  fiir  Gynak.,  1887,  vol.  xxxii.  p.  50. 


EMBRYOTOMY.  685 

§  2.  Decapitation. — Decapitation  is  the  operation  by  which  the 
head  of  the  foetus  is  severed  from  its  body,  and  was  known  to  the 
ancient  classic  peoples. 

It  is  indicated  in  transverse  presentation,  when  version  has  been 
neglected  or  has  proved  impossible,  or  would  be  too  dangerous,  as  it 
would  be  likely  to  produce  rupture  of  the  uterus. 

As  a  rule,  the  arm  is  prolapsed  and  the  shoulder  impacted  in  the 
pelvis.  By  vaginal  examination  we  feel  the  shoulder  or  part  of  the 
back,  and  when  with  difficulty  we  succeed  in  entering  farther  we  may 
reach  the  axilla  or  the  ribs  or  the  shoulder-blade,  so  as  to  be  able  to 
iind  out  how  the  foetus  lies. 

Modus  Operandi. — Decapitation  is  performed  in  the  easiest  and 
safest  w^ay  by  means  of  Braun's  "  Schliisselhaken," — i.e.,  keyhook 
(Fig.  484).     This  consists  of  a  steel  rod  bent  at  an  acute  rounded-oflf 

Fig.  484. 


Braun's  key-hook, 

angle  and  ending  in  a  Uttle  round  knob,  and  a  handle  set  at  right 
angles  to  the  stem. 

The  patient  is  placed  in  dorsal  position,  anaesthetized  and  disin- 
fected as  usual.  The  accoucheur  introduces  his  left  hand  into  the 
uterus,  if  the  head  lies  in  the  right  side,  seizes  the  neck,  with  the  index 
and  middle  finger  behind  and  the  thumb  in  front  (Fig.  485),  and  pulls 
it  down  as  much  as  possible.  Next,  he  introduces  the  hook  on  the 
flat  until  it  has  passed  the  neck,  when  he  turns  it  around  so  as  to 
make  it  ride  over  the  neck.  The  fingers  should  be  kept  in  contact  with 
the  knob  of  the  instrument,  which  is  pulled  straight  down  as  far  as 
possible,  and  then  rotated  under  continued  traction,  severing  the  ver- 
tebrae, which  are  heard  cracking.  The  muscles  and  the  skin  are  torn 
with  the  instrument  or  severed  with  scissors. 

If  the  head  lies  in  the  left  side,  the  right  hand  should  be  used  to 
fasten  the  neck,  and  the  instrument  worked  with  the  left  hand.  Other- 
wise the  movements  will  be  communicated  to  the  head,  which  may 
injure  the  uterus. 


686 


OBSTETRIC    OPERATIONS. 


If  this  instrument  is  not  at  hand,  the  neck  may  be  severed  with 
strong  blunt  scissors  or  the  chain  or  wire  of  an  ecraseur,  if  it  can  be 
brought  around  the  neck,  which  may  be  done  as  we  have  explained 

in   speaking  of  impacted 
Fig.  485.  breech  presentation   (pp. 

387-389).  If  scissors  are 
used,-  the  arm  should  be 
pulled  well  down  in  the 
direction  of  the  body  of 
the  foetus,  so  as  to  put  the 
neck  on  the  stretch. 

When  once  the  head  is 
separated  from  the  body^ 
the  latter  is  easily  ex- 
tracted by  the  prolapsed 
arm,  w^hereas  the  head 
may  be  quite  difficult  to 
remove.  If  the  arm  is 
not  prolapsed,  the  accou- 
cheur should  try  to  bring 
it  down.  If  he  does  not 
succeed  in  this,  he  may 
try  a  blunt  hook  applied 
in  the  axilla  (p.  389,  Fig. 
305). 

The  best  way  of  re- 
moving the  head  is  to  have 
an  assistant  press  it  down 
while  the  accoucheur  per- 
forates it  and  extracts  it 
with  cranioclast  or,  if  that 
instrument  is  not  availa- 
ble, with  the  cephalotribe 
or  the  obstetric  forceps. 
Great  care  should  be  taken  to  turn  the  stump  of  the  neck  in  such  a 
way  that  it  does  not  wound  the  soft  tissues  of  the  mother. 

§  3.  Evisceration. — Evisceration^  or  exenteration,  is  an  operation  by 
which  the  contents  of  the  thorax  and  abdomen  of  the  foetus  are  re- 
moved in  order  to  make  it  small  enough  to  be  born.  This  operation 
is  indicated  in  cases  similar  to  those  in  which  decapitation  is  used, 
if  the  neck  is  not  within  reach. 

A  perforator,  strong  blunt  scissors,  craniotomy-forceps,  and  trac- 
tion-forceps are  the  instruments  needed.  A  crotchet  may  also  be 
used  to  advantage.     Protected  by  the  left  hand  or,  better,  by  means 


Braun's  hook  applied. 


EMBRYOTOMY.  687 

of  a  large  Sims  speculum,  the  axilla  or  back  of  the  foetus  is  perforated, 
and  through  the  opening  thus  formed  the  heart  and  lungs  are  cut 
loose  and  drawn  out.  If  this  does  not  yet  suffice,  the  diaphragm  is 
attacked  and  an  attempt  made  to  get  the  large  liver  out,  but  this  will 
probably  be  easier  by  making  another  opening  in  the  abdomen. 
When  the  foetus  is  sufficiently  diminished  it  is  seized  by  the  feet  and 
turned.  If  this  is  not  possible,  the  vertebral  column  and  the  soft  tis- 
sues are  cut  with  strong  scissors  and  each  half  of  the  foetus  is  extracted 
separately  {spondylotomy). 

§  4.  Brachiotomy. — Brachiotomy  is  an  operation  by  which  the 
arm  is  exarticulated.  As  we  have  seen  above,  the  prolapsed  arm  may 
be  very  useful  in  performing  embryotomy,  and  the  accoucheur  should 
therefore  take  good  care  not  to  cut  it  off,  by  which  he  would  not  gain 
any  space  and  might  make  the  other  manipulations  indicated  more 
difficult.  In  exceedingly  rare  cases  it  may  be  an  advantage  to  ex- 
articulate  the  non-prolapsed  arms,  which  is  then  done  with  strong 
scissors. 

§  5.  Cleidotomy. — We  have  seen  (p.  193)  that  even  in  normal 
labor  the  delivery  of  the  shoulders  may  offer  some  difficulty  and 
call  for  the  accoucheur's  interference.  If  the  shoulders  are  arrested 
above  the  pelvic  brim,  it  is  because  they  are  too  wide,  and  particu- 
larly because  they  occupy  the  anteroposterior  diameter.  The  accou- 
cheur should  then  introduce  four  fingers  and  push  on  the  anterior 
shoulder,  trying  to  place  the  shoulders  in  the  transverse  diameter  of 
the  brim. 

The  too  great  width  of  the  shoulders  is  frequently  found  in  hemi- 
cephali  (Fig.  319,  p.  402).  With  a  normal  head  it  may  become  the 
cause  of  death  of  the  foetus  after  the  head  is  born.  If  the  manoeuvres 
recommended  to  help  the  shoulders  down  and  out  do  not  succeed, 
and  the  foetus  dies,  and  the  mother  is  in  good  condition,  we  may  wait 
and  see  the  effect  of  labor-pains,  by  which  the  shoulders  may  be 
turned  into  the  transverse  diameter  and  descend.  But  if  this  does 
not  take  place,  and  a  speedy  delivery  is  called  for,  especially  if  the 
patient  is  feverish  or  the  uterus  threatens  to  rupture,  an  operation 
called  cleidotomy  may  be  performed,  by  which  the  collar-bones  and 
perhaps  also  the  upper  ribs  are  broken.  It  may  be  done  with  scissors 
or  the  perforator.  When  the  collar-bones  are  cut,  the  shoulders 
move  nearer  to  the  sternum,  and  the  child  can  be  born. 


PART  n.— ABNORMAL    PUERPERY. 


CHAPTER   I. 
PUERPERAL   INFECTION. 

§  1.  Nature  of  the  Disease. — By  puerperal  infection  is  here  un- 
derstood all  the  manifold  inflammatory  conditions  in  puerperal  women 
caused  by  microbes  or  their  products,  except  eruptive  fevers  and  in- 
flammation of  the  breasts.^ 

Some  authors  take  the  term  puerperal  infection  in  a  narrower  sense, 
using  it  only  to  designate  conditions  in  wdiich  an  invasion  of  microbes 
takes  place  into  the  tissues  ;  while  they  call  the  absorption  of  the 
poisonous  fluid  produced  by  the  microbes,  the  so-called  toxins,  from 
the  surface  into  the  tissue,  intoxication.  It  is  claimed  that  intoxication 
is  less  dangerous.  But  this  appears  too  theoretical  to  the  writer. 
Since  the  absorbed  toxins  may  cause  disease  and  death,  and  since 
in  treating  a  sick  puerpera  we  do  not  know  what  ultimately  the 
pathologist  and  bacteriologist  will  find  in  her  dead  body,  I  retain  the 
definition  I  have  followed  in  earlier  writings  on  the  subject. 

In  most  books  the  condition  is  called  puerperal  fever,  a  denomi- 
nation from  which  the  writer  entirely  abstains.  Not  many  years  ago 
this  expression  was  used  to  designate  what  was  believed  to  be  a  dis- 
ease sui  generis,  and  it  has  left  so  unsavory  a  record  that  it  fills  the 
laity  with  terror.  In  most  countries  there  are  special  laws  concerning 
it.  As  it  is  looked  upon  as  a  most  dangerous  contagious  disease,  mid- 
wives  are  ordered  to  report  it  to  the  medical  inspector  of  the  district 
in  which  they  practise,  and  are,  as  a  rule,  forbidden  for  a  time  after  a 

*  Garrigues,  "Dissecting  Metritis,"  N.  Y.  Med.  Jour.,  1882,  vol.  xxxvi.  p.  587  ; 
"  Dissecting  Metritis,"  Archives  of  Medicine,  April,  1883  ;  "  Dissecting  Metritis," 
Med.  Record,  1883,  vol.  xxiv.  p.  664  ;  "  Prevention  of  Puerperal  Infection,"  ibid., 
December  29,  1883,  vol.  xxiv.  pp.  703-706;  "Prevention  of  Puerperal  Infec- 
tion," N.  y.  Med.  Jour.,  1884,  vol.  xxxix.  p.  243;  "The  Opium  Plan  in  Puer- 
peral Fever,"  ibid.,  1885,  vol.  xli.  p.  98  ;  "Puerperal  Diphtheria,"  Trans.  Amer. 
Gynaecol.  Soc,  1885,  vol.  x.;  Practical  Guide  in  Antiseptic  Midwifery,  Detroit, 
Michigan,  Geo.  S.  Davis,  1886;  "Puerperal  Infection,"  in  American  System  of 
Obstetrics,  edited  by  Hirst,  Philadelphia,  1889,  Lea  Bros.,  vol.  ii.  pp.  291,  400; 
"Ueber  Metritis  Dissecans,"  Archiv  fiir  Gynilk.,  1892,  vol.  xxxviii.,  No.  3  ;  "Rep- 
rehensible, Debatable,  and  Necessary  Antiseptic  Midwifery,"  Med.  News,  November 
26,  1892;  "Puerperal  Infection,"  in  American  Text-Book  of  Obstetrics,  edited 
by  E.  C.  Norris,  Philadelphia,  Saunders  &  Co.,  1895,  pp.  683-734  ;  "The  Present 
Status  of  the  Treatment  of  Puerperal  Infection,"  St.  Louis  Courier  of  Medicine, 
January,  1901. 


PUERPERAL  INFECTION.  689 

case  of  this  nature  has  occurred  in  their  practice  to  attend  to  other 
confinements.  But  it  is  impossible  to  define  "  puerperal  fever"  in  this 
sense  of  the  word.  Modern  German  authors  use  the  term  for  every 
rise  in  temperature  in  childbed,  which  perhaps  is  due  to  retention  of 
faeces  or  an  emotion,  and  has  no  connection  with  microbes.  There  is 
so  much  more  objection  to  the  term  "  puerperal  fever"  as  in  some  of 
the  worst  cases  there  is  no  fever  at  all. 

Some  use  the  term  "  puerperal  septiccemia,'''  which  is  so  far  an 
improvement  as  it  reminds  one  of  the  identity  of  puerperal  infection 
and  wound  infection  ;  but  the  expression  leads  to  constant  confusion. 
It  is  too  wide  because  the  same  word  is  used  to  designate  particular 
forms  of  puerperal  infection,  and  forms  which  are  rather  distinct  from 
one  another.  Thus,  some  use  "  septicaemia"  in  the  sense  of  lym- 
phangioperitonitis,  as  opposed  to  uterophlebitis,  which  they  call  pyce- 
mia.  And  all  use  it  to  designate  a  condition  in  which  septic  material 
circulates  with  the  blood-current  throughout  the  body,  which  ety- 
mologically  is  the  meaning  of  the  word.  But  there  are  in  puerperae 
many  inflammatory  conditions  which  certainly  are  due  to  puerperal 
infection  and  still  hardly  ever  lead  to  a  general  infection  of  the  whole 
system. 

The  term  "  puerperal  infection "  is  open  to  the  criticism  that  it 
means  a  cause,  and  not  the  effect  produced  by  it ;  but  this  is  not 
without  analogy.  The  word  "  cold,"  for  instance,  means  originally  a 
low  degree  of  temperature,  but  by  extension  it  is  also  used  to  desig- 
nate the  disturbance  caused  in  the  human  body  by  exposure. 

By  using  the  term  "  puerperal  infection"  we  have  the  advantage  of 
having  a  general  expression  that  covers  all  cases,  mild  and  severe,  all 
disturbances,  local  and  general,  in  the  equilibrium  of  health.  We  are 
forcibly  reminded  of  the  nature  of  the  disease  and  the  possibility  in 
nearly  all  cases  of  warding  it  off,  whereas  the  preceding  generation 
attributed  it  to  some  unknown  and  unconquerable  change  in  the 
atmosphere  or  looked  upon  it  as  a  direct  dispensation  of  God,  to 
whose  will  mankind  reverently  had  to  bow  and  submit.  We  are 
turned  in  the  right  direction  to  find  means  of  relief  and  cure  when 
the  disease  has  developed.  We  stand  also  on  solid  scientific  ground, 
for,  as  we  presently  shall  see,  the  mildest  and  the  severest  cases  of 
morbidity  are  usually  caused  by  the  same  microbes. 

Puerperal  infection  nearly  always  is  due  to  infection  of  wounds 
in  the  genital  tract.  We  know  that  a  clean  wound,  kept  clean,  heals 
and  does  not  cause  general  disease.  When  suppuration,  diphtheria, 
gangrene,  or  erysipelas  sets  in,  it  is  due  to  the  presence  of  microbes, 
and  so  it  is  with  puerperal  infection. 

Wounds. — The  whole  inside  of  the  body  of  the  womb  is  one  large 
wound,  the  separation  between  the  ovum  and  the  uterus  taking  place 

44 


690  ABNORMAL   PUERPERY. 

in  the  areolar  tissue  of  the  decidua,  and  at  the  placental  site  there  are 
numerous  veins,  either  with  freshly  agglutinated  walls  or  plugged  by 
thrombi.  In  this  respect  the  human  economy  is  exposed  to  much 
greater  danger  than  that  of  animals :  with  them,  as  a  rule,  the  process 
of  expelling  their  offspring  is  not  more  difficult  than  the  act  of  defeca- 
tion. The  placental  site  in  their  womb  either  regains  its  epithelium 
before  the  loosening  of  the  placenta  or  recovers  it  in  a  very  short  time, 
sometimes  even  in  a  few  minutes.  This  explains  why  puerperal  infec- 
tion is  not  produced  in  them  by  injection  of  toxines  into  the  vagina 
and  uterus,  while  the  same  fluid  injected  into  the  tissues  under  the 
protecting  epithelium  causes  the  disease. 

The  cervix  is  nearly  always  more  or  less  torn  near  the  os  in  con- 
sequence of  the  forced  expansion  during  the  passage  of  the  foetus, 
and  sometimes  these  tears  extend  deep  into  the  parametrium.  At  the 
entrance  to  the  vagina  there  are  nearly  always  some  tears,  at  least  in 
primiparse.  The  perineum  also  frequently  is  more  or  less  lacerated. 
Finally,  there  are  numerous  abrasions  in  the  cervical  canal,  the  vagina, 
and  the  vulva.  It  will  thus  be  seen  that  there  are  many  wounded 
surfaces  through  which  infection  may  occur. 

Microbes. — The  obstetrician  has  to  look  to  the  bacteriologist  for 
information  in  regard  to  the  organisms  that  cause  puerperal  infection. 
A  few  years  ago  these  scientists  spoke  with  great  assertion,  and  every- 
thing seemed  to  be  clear  and  easy ;  but  accumulating  experience  has 
made  them  more  diffident,  and  the  outsider  sees  many  discrepancies 
in  the  results  they  arrive  at.  In  1899  the  German  Gynaecological 
Society  had  chosen  "puerperal  fever"  as  a  special  subject  of  discus- 
sion. Some  of  the  greatest  obstetricians  and  bacteriologists  of  Ger- 
many were  present,  and  the  world  would  be  inclined  to  expect  special 
light  from  such  an  assemblage  of  men  on  such  a  subject  in  a  country 
where  probably  greater  attention  is  paid  to  bacteriology  than  any- 
where else.  One  is,  therefore,  rather  disappointed  to  find  how  far 
they  are  from  unanimity,  either  in  the  results  of  their  bacteriological 
investigation  or  in  the  practical  methods  of  treatment  based  thereon. 
Even  such  a  fundamental  fact  as  the  presence  or  absence  of  fever- 
producing  microbes  in  the  vagina  of  pregnant  and  parturient  women 
seems  still  to  be  doubtful.  Kroenig,^  who  used  to  be  the  banner- 
carrier  of  those  who  denied  their  presence  in  health,  has  changed 
his  mind  in  this  respect.     (Compare  p.  125.) 

All  agree  that  there  are  no  microbes  in  the  uterus  before  de- 
livery, but  Burkardt^  has  examined  the  interior  of  the  womb  of 
healthy  women  during  the  puerperium.  During  the  first  five  days, 
and  sometimes  as  much  as  eight,  no  germs  were  found.  After  the 
eleventh  day  they  abound,  and  there  are  even  plenty  of  streptococci, 

^  The  bibliographic  references  are  found  at  the  end  of  the  chapter,  p.  746. 


PUERPERAL    INFECTION.  691 

which  are  declared  by  all  to  be  the  most  common  and  most  dangerous 
cause  of  puerperal  infection.  But  since  the  patients  all  remained 
well,  except  for  a  slight  rise  in  temperature,  Burkardt  thinks  there 
must  be  two  kinds,  the  highly  dangerous  streptococcus  pyogenes  and 
an  innocuous  streptococcus  saprogenes,  but  so  far  there  is  no  means 
of  distinguishing  them  from  each  other. 

Koblanck^  found  streptococci  in  the  vagina  of  nineteen  puerperse, 
of  whom  thirteen  Avere  perfectly  well,  and  six  had  only  a  slight  rise 
in  temperature.  The  theory  has,  therefore,  been  advanced  that  the 
slight  fever  frequently  observed  in  puerperal  women  is  due  to  a  sec- 
ondary infection,  the  parturient  canal  being  a  wound  that  easily  can 
become  infected  from  the  skin,  with  which  it  is  continuous. 

There  is,  however,  no  doubt  that  puerperal  infection  is  due  to 
microbes.  The  most  important  of  these  is  the  streptococcus  jyyogenes, 
a  microscopic  plant  that  is  found  nearly  everywhere,  and  which,  there- 
fore, can  easily  be  brought  into  the  genital  tract  by  physicians  and 
midwives,  even  if  it  is  not  found  there  before.  These  streptococci 
can  also  wander  spontaneously  into  the  genitals,  and  are  even  found 
in  new-born  children.*  Many  observers  state  that  the  streptococci 
found  in  patients  suffering  from  puerperal  infection  are  identical  with 
the  streptococcus  of  erysipelas  and  of  suppuration. 

Next  to  streptococci  the  most  important  microbes  in  puerperal 
infection  are  staphylococcus  aureus  and  staphylococcus  pyogenes  albus. 
Of  these  the  latter  is  always  found  on  the  skin  of  man  and  in  the 
secretion  of  the  vagina,  and  the  former  only  a  little  less  frequently. 

Very  serious  illness  and  death  may  also  be  due  to  bacterium  coli 
commune,  a  normal  inmate  of  the  bowel,  or  to  gonococcus  or  pneumo- 
coccus,  organisms  that  are  exceedingly  common.  These  three  are 
often  found  in  company  with  streptococcus,  but  they  have  also  been 
found  to  cause  the  most  severe  inflammation  alone.  The  bacillus 
diphtherice  of  Klebs-Loffler  has  also  been  found  as  cause  of  infec- 
tion of  the  genitals  of  the  diphtheritic  type  and  combined  with  the 
usual  throat  affection. 

Different  Forms  of  Infection. — The  infection  maybe  local  or  general, 
the  first  of  which  is  limited  to  a  comparatively  small  area,  while  the 
second  implicates  the  whole  system,  and,  therefore,  is  much  more 
dangerous  than  the  former.  We  must  also  distinguish  between  putrid 
infection  and  septic  infection,  both  of  which  may  be  local  or  general. 
General  putrid  infection  is  called  saprcemia,  and  general  septic  infection 
septicaemia.  It  will  be  noticed  that  the  word  septicaemia  here  is  taken 
in  an  entirely  different  sense  from  that  in  which  it  is  made  to  designate 
lymphangioperitonitis  only. 

Putrefaction  and  saprsemia  are  due  to  many  different  schizomycetes, 
the  so-called  saprophytes,  minute  organisms  which  are  allied  to  algae, 


692  ABNORMAL   PUERPERY. 

and  are  found  all  over  the  world  in  streams,  plants,  animals,  etc. 
They  are  anaerobic, — that  is  to  say,  they  cannot  thrive  in  a  medium 
containing  free  oxygen.  They  get  the  oxygen  needed  for  their  sus- 
tenance by  butyric,  alcoholic,  or  other  fermentation  which  they  incite. 
By  their  growth  and  multiplication  these  organisms  produce  certain 
chemical  substances,  the  so-called  toxines,  a  kind  of  ptomaines  which 
give  rise  to  fever.  Ptomaines  are  alkaloids  produced  in  dead  vegetable 
and  animal  tissues.  They  are  produced  only  by  microbes,  and  are 
generally  poisonous.  Leucomaines  are  similar  alkaloids  produced  in 
living  animal  tissues  as  a  result  of  their  physiological  activity,  and  are 
harmless,  unless  their  excretion  is  interfered  with. 

The  changes  occurring  in  puerperal  infection  may  be  due  to  the 
absorption  of  ptomaines  and  leucomaines  alone,  without  the  presence 
of  microbes,  but  in  the  vast  majority  of  cases  the  microbes  are  present. 
The  saprophytes  are  generally  brought  into  the  interior  of  the  uterus 
mechanically. 

Septicaemia  is  due  to  a  few  well-known  species  of  microbes  that 
actively  enter  the  tissues  of  the  body,  which  they  injure  through  their 
growth,  and  by  their  distribution  throughout  the  economy  they  may 
so  change  the  chemical  processes  and  normal  functions  of  the  organs 
that  death  ensues.  These  microbes  are,  as  stated  above,  chiefly  strep- 
tococci, and  next  to  them  staphylococci,  but  occasionally  also  bacterium 
coli  commune,  the  gonococcus,  the  pneumococcus,  the  bacillus  of 
diphtheria,  the  bacillus  aerogenes  capsulatus  of  Welch  and  Nuttall,  and 
the  bacillus  of  malignant  oedema  of  Frankel  are  the  agents  at  work  in 
puerperal  infection.  These  are  called  pathogeniG  microbes,  which 
means  causing  disease,  in  contradistinction  to  other  microbes  called 
non-pathogenic^  which  only  cause  putrefaction.  At  first  streptococcus 
pyogenes,  staphylococcus  aureus,  and  staphylococcus  pyogenes  albus 
were  thought  to  be  the  only  pathogenic  microbes  ;  but  with  increasing 
experience  the  list  has  become  considerably  longer,  and  the  whole 
distinction  does  not  seem  to  be  of  much  value.  The  same  species 
may  be  pathogenic  and  non-pathogenic. 

The  infection,  in  the  majority  of  cases,  starts  from  the  endometrium, 
and,  according  to  what  has  just  been  said,  ^putrid  endometritis  has  been 
distinguished  from  a  septic  endometritis.  In  putrid  endometritis  there 
is  a  superficial  layer  of  necrotic  tissue,  and  under  that  a  thick  layer  of 
granulation  tissue  full  of  leucocytes,  or  phagocytes,  which  may  engulf 
the  microbes  and  render  them  innocuous.  The  necrobiotic  layer  is 
covered  with  saprophytic  cocci  and  bacilK,  but  they  never  enter  the 
granulation  layer. 

Septic  endometritis  is  either  local  or  general.  In  the  local  form 
the  inside  of  the  uterus  is  much  hke  that  of  the  putrid,  but  in  addition 
to  saprophytes  streptococci  are  found. 


PUERPERAL   INFECTION.  693 

General  septic  endometritis  appears  under  two  distinct  and  very 
different  forms,  the  lymphatic  and  the  thrombophlebitic.  In  the 
lymphatic  form  there  is  a  mixture  of  saprophytes  and  streptococci  on 
the  endometrium,  but  the  layer  of  granulation  tissue  is  much  thinner 
than  in  the  putrid  endometritis,  and  in  the  most  severe  cases  it  is 
altogether  absent.  The  veins  of  the  placental  site  are  closed  by  agglu- 
tination, and  there  are  no  thrombi.  In  the  severest  cases  the 
microbes  enter  the  fine  lymph-spaces  between  the  tissue  elements  ;  in 
the  less  rapid  they  generally  follow  the  trunks  of  the  large  lymphatic 
vessels.  From  the  lymph-vessels  they  enter  the  surrounding  tissue, 
causing  necrosis.  This  lymphatic  form  often  starts  from  the  cervix. 
In  septic  peritonitis  the  infection-carriers  do  not  go  through  the  Fallo- 
pian tubes,  but  through  the  lymph-spaces  and  lymph-vessels  of  the 
uterine  wall. 

In  the  thrombophlebitic  form  of  general  infection  the  endometrium 
is  like  that  of  the  local  form,  except  at  the  placental  site.  Saprophytes 
and  streptococci  are  found  together  on  the  surface,  but  they  never 
penetrate  the  tissues,  except  at  the  placental  site.  Here  the  veins  are 
plugged  with  thrombi,  into  which  saprophytes  and  streptococci  enter ; 
but  while  the  saprophytes  stay  near  the  surface,  the  streptococci,  find- 
ing the  soil  particularly  favorable,  penetrate  deeper,  and  soon  the 
thrombus  becomes  disintegrated  and  forms  a  detritus,  a  process  that 
may  extend  into  the  broad  ligaments. 

But  the  author  of  this  distinction  between  putrid  and  septic  endo- 
metritis (Bumm)  himself  admits  that  the  two  forms  may  be  combined, 
and  another  bacteriologist  (Kronig^)  declares  that  saprophytes  may 
penetrate  the  tissues  and  give  rise  to  parametritis  and  iDerimetritis. 

The  diphtheritic  form  of  puerperal  infection  begins  in  the  mucous 
membrane  of  the  vulva,  vagina,  or  uterus,  or  in  a  tear  extending  into 
the  surrounding  tissue.  Patches  like  those  found  on  diphtheritic  sores 
or  in  the  throats  of  patients  affected  with  diphtheria  make  their  appear- 
ance. As  a  rule,  it  is  the  same  above-mentioned  streptococcus  pyogenes 
which  invades  the  tissues  in  this  diphtheritic  form,  but  the  true  Klebs- 
Loffler  bacillus  of  diphtheria  has  also  been  found. 

The  difference  in  symptoms  and  danger  in  different  cases  may  be 
accounted  for  in  many  ways.  The  power  of  resistance  of  the  attacked 
individual  varies  much.  A  woman  who  is  debilitated  by  previous  dis- 
ease, or  who  has  lost  much  blood,  is  more  likely  to  succumb  than  one 
in  physically  good  condition.  The  number  of  the  invaders  is  also 
important.  The  phagocytes  may  be  able  to  devour  a  certain  number, 
but  when  the  limit  is  passed  they  are  no  longer  equal  to  the  task  of 
neutralization.  The  anatomical  structure  and  connections  of  the  part 
invaded  explain  many  differences  in  the  ravages  wrought  by  the 
microbes.     If  these  enter  one  lymphatic,  they  may  only  be  carried  to 


694  ABNORMAL    PUERPERY. 

the  nearest  lymphatic  gland  and  made  harmless  there.  If  they  enter 
another,  they  may  be  carried  straight  to  the  peritoneum,  the  pleura, 
and  the  pericardium.  Or  a  thrombus  in  a  uterine  vein  may  break 
down  and  the  microbes  in  it  may  be  carried  through  the  vena  cava 
and  the  right  half  of  the  heart  to  the  lungs,  where  they  are  arrested  in 
one  of  the  fine  branches  of  the  pulmonary  artery  and  form  an  abscess, 
from  which  they  may  return  to  the  left  side  of  the  heart  and  be  dis- 
tributed in  all  parts  of  the  body. 

The  difference  in  virulence  seems  to  be  the  most  important  of  all. 
This  is  a  property  of  the  protoplasm  that  shows  itself  in  abundant 
proliferation  and  increased  power  of  resistance  to  the  attacks  of  the 
cells  in  the  invaded  body.  This  virulence  is  diminished  by  artificial 
culture  and  increased  when  the  microbes  pass  through  the  body  of  an 
animal.  The  virulence  is  particularly  enhanced  in  the  system  of  a  sick 
person.  Thus  the  streptococci  taken  from  a  case  of  puerperal  infec- 
tion, erysipelas,  smallpox,  or  scarlet  fever  are  in  the  highest  state  of 
virulence.  Staphylococci  are  most  dangerous  when  they  come  from 
a  fresh  abscess. 

Bacterium  coli  commune  is  harmless  in  the  bowel,  and  does  not 
seem  to  affect  tears  in  the  perineum  much,  but  the  same  organism  be- 
comes highly  dangerous  when  it  enters  the  uterus,  the  appendages,  or 
the  peritoneal  cavity. 

Anaerobia,  which  are  of  little  importance  on  the  surface,  may  enter 
the  tissues  and  give  rise  to  the  worst  kind  of  infection,  especially  the 
bacillus  aerogenes  capsulatus  and  the  bacillus  of  malignant  oedema. 

In  the  writer's  opinion  "  puerperal  fever,"  as  it  is  generally  under- 
stood in  the  profession  here,  is  nothing  but  the  most  severe  puerperal 
infection.  Local  infection  is  less  dangerous  than  general  infection. 
Putrid  infection  is  not  so  dangerous  as  septic  infection,  but  any  local 
infection  may  become  general^  and  a  putrid  infection  may  cause  septiccemia 
and  death. 

Septiccemia  in  Children. — Identically  the  same  disease  that  appears 
in  puerperal  women  through  infection  may  develop  in  children.  The 
mother  of  the  sick  child  may  be  infected  or  not.  Infection  in  the 
child  generally  enters  through  the  navel,  but  it  may  also  gain  entrance 
through  sores  in  the  mouth  or  through  an  accidental  wound.  It  may 
also  come  from  decomposed  liquor  amnii  which  the  foetus  has  drawn 
into  its  lungs  during  labor.  When  the  normal  partition  between  the 
maternal  and  the  fetal  circulation  breaks  down,  the  microbes  may 
even  pass  from  the  mother  to  the  foetus  through  the  placenta.  If  not 
acquired  before  its  birth,  the  infecting  substance  may  be  brought  to 
the  infant  by  doctors  or  nurses  ;  it  may  cling  to  any  object  with  which 
the  child  comes  in  contact,  or  it  may  float  in  the  air  which  it  inspires. 
The  sources  of  the  infection  in  children  are  the  same  as  in  puerperse. 


PUERPERAL   INFECTION.  695 

§  2.  Etiology, — Experience  shows  that  puerperae  are  more  liable 
to  disease  than  other  women,  a  fact  which  can  easily  be  accounted 
for.     The  causes  of  puerperal  infection  are  predisposing  or  exciting. 

Predisposing  Causes. — During  pregnancy  the  blood  of  the  woman 
undergoes  great  changes.  It  increases  in  bulk,  but  is  more  watery. 
Haemoglobin,  iron,  albumin,  fat,  and  phosphorus  decrease,  while  the 
fibrin  is  much  increased.  The  red  blood-corpuscles  are  reduced  in 
number,  while  the  colorless  are  more  numerous  than  in  non-pregnant 
women.  The  plethora,  hyperinosis,  and  leucocythaemia  predispose  to 
inflammation. 

The  blood-vessels  and  lymphatics  become  dilated,  which  predis- 
poses to  the  formation  of  thrombi.  These  furnish  an  excellent  soil 
for  the  propagation  of  microbes,  and  when  they  break  down  their 
infecting  debris  may  be  carried  to  the  lungs  and  give  rise  to  the  forma- 
tion of  new  infectious  foci  in  all  parts  of  the  body. 

The  nervous  system  is  in  a  state  of  great  excitement.  Headache, 
toothache,  vertigo,  longings,  and  dislikes  are  common  features  of  the 
pregnant  state.  The  patient  is  also  frequently  inclined  to  sadness,  and 
she  is  highly  sensitive  to  unpleasant  impressions.  The  presence  of  an 
uncongenial  person  may  arrest  labor-pains.  Bad  news  may  send  her 
temperature  up  several  degrees.  Shame  in  the  unmarried,  dread  of 
financial  difficulties  in  the  married,  often  prey  on  their  minds  and 
lower  their  power  of  resistance.  Since  every  muscular  contraction 
and  all  secretory  functions  are  under  the  control  of  the  nervous  sys- 
tem, it  may  influence  the  progression,  stagnation,  distribution,  and 
expulsion  of  the  microbes. 

Nervous  exhaustion  from  pain  or  loss  of  blood  lowers  the  patient's 
vitality  even  in  normal  labors  ;  and  if  there  is  any  obstruction,  or  the 
membranes  rupture  early,  the  danger  of  infection  increases  very  much. 
When  the  cervical  plug  is  expelled,  and  the  liquor  amnii  has  drained 
off,  the  microbes  have  free  access  to  the  interior  of  the  uterus  and  the 
ovum.  Preceding  disease,  especially  diabetes  or  eclampsia,  and  a 
weak  heart  lower  the  power  of  resistance.  There  may  also  be  a  local 
loss  of  power  of  resistance  when  the  tissues  are  oedematous,  infiltrated 
with  blood,  or  bruised. 

All  manipulations  by  which  the  genital  tract  is  entered  with  fingers, 
hands,  or  instruments  enhance  the  danger  enormously. 

The  artificial  detachment  of  the  placenta,  or  its  insertion  low  down 
in  the  uterus,  easily  leads  to  infection.  The  death  of  the  foetus  or 
prolapse  of  the  cord  or  limbs  facilitates  it. 

Normally,  the  uterus  contracts  forctoly  after  the  expulsion  of  the 
child,  and  the  walls  of  the  veins  at  the  placental  site  are  agglutinated. 
But  if  this  contraction  is  defective,  either  the  woman  bleeds  to  death 
or  the  veins  are  closed   by  fibrinous  clots,  the    ends    of   which  jut 


696  ABNORMAL    PUERPERY. 

into  the  uterine  cavity  and  offer  an  excellent  soil  for  the  propaga- 
tion and  penetration  of  microbes. 

The  separation  between  mother  and  child  normally  takes  place  in 
the  areolar  layer  of  the  decidua,  but  large  pieces  of  decidua  or  chorion 
may  be  torn  off  from  the  ovum  and  remain  in  the  uterus,  where  soon 
they  become  covered  with  saprophytes.  Still  worse  is  the  retention 
of  a  cotyledon  of  the  placenta,  which  is  particularly  apt  to  happen 
in  the  cornua,  near  the  ostium  uterinum  of  the  Fallopian  tube. 

The  entirely  normal  lochial  discharge  is  an  excellent  culture 
medium  for  all  germs  and  possesses  phlogogenic  properties.  Espe- 
cially if  the  lochia  are  retained  in  the  uterine  cavity — so-called  lochi- 
ometra — they  are  apt  to  cause  fever,  which  disappears  when  the 
uterus  is  lifted  up  and  vaginal  douches  are  given. 

During  pregnancy  there  is  a  strong  current  from  the  mother  to 
the  child.  After  delivery  this  is  reversed.  The  enlarged  organs  and 
swollen  tissues  have  to  be  reduced.  They  undergo  fatty  degeneration 
and  involution,  the  effete  matter  being  carried  from  the  genitals  to  the 
rest  of  the  body  of  the  puerpera. 

Primiparse  are  more  exposed  to  infection  than  pluriparse.  The 
canal  is  narrower,  the  tissues  are  softer,  and  labor  lasts  longer. 

Deliveries  in  a  general  hospital,  which  until  quite  recently  were  a 
common  occurrence,  are  more  dangerous  than  those  in  special  lying-in 
hospitals  or  the  patients'  homes.  There  is  much  greater  danger  of 
infectious  substances  being  carried  from  other  patients  to  the  puer- 
pera. Even  the  accumulation  of  many  puerperse  in  an  insufficient 
space  predisposes  to  disease  among  them.  Parturition  should  not 
take  place  in  a  room  where  there  are  puerperse,  the  discharges  from 
the  latter  being  particularly  dangerous  to  the  parturient  woman. 

The  exciting  cause  is,  as  we  have  seen  above,  the  attack  by  microbes 
of  the  wounds  that  always  are  found  in  a  puerperal  woman.  The 
microbes  may  have  been  in  the  genital  tract  before  delivery,  they  may 
be  brought  in  by  obstetric  manipulations,  or  they  may  wander  in  by 
themselves.  The  rate  of  progression  of  staphylococcus  aureus  was 
found  to  be  80  centimetres  in  56  hours  (Kronig). 

Nature  to  some  extent  protects  the  parturient  woman  and  puer- 
pera against  infection :  the  cervical  plug,  the  blood  flowing  out  from 
wounds,  the  gush  of  water  Avhen  the  membranes  rupture,  the  strong 
uterine  contractions,  are  all  calculated  to  keep  the  enemy  out,  but  are 
not  always  equal  to  the  task. 

Sources  of  the  Infection. — The  morbific  element  may  come  from  a 

woman  similarly  affected,  from  suppuration,  from  decaying  substances 

within  or  without  the  body,  or  from  some  zymotic  disease,  especially 

erysipelas  or  diphtheria,  all  of  which  we  shall  illustrate  by  examples. 

Contagion. — The  Enghsh  physician  Denman  (1733-1815)  was  the 


PUERPERAL   INFECTION.  697 

first  to  point  out  that  "puerperal  fever"  might  be  carried  from  one 
puerpera  to  another.  In  this  country  this  view  was  elucidated  in  a 
masterly  essay  by  Oliver  Wendell  Holmes/  whose  work  as  a  physician 
and  teacher,  is  apt  to  be  overlooked  on  account  of  his  fame  as  poet  and 
author.  Nowadays  the  contagiousness  of  puerperal  infection  is  uni- 
versally admitted,  and  the  only  mooted  point  is  whether  the  microbes 
necessarily  are  carried  by  means  of  some  solid  or  fluid  substance 
from  one  patient  to  the  other,  or  may  float  through  the  air,  a  point 
to  which  we  presently  shall  return. 

Suppuration. — That  pus  can  produce  "puerperal  fever"  was 
demonstrated  by  Semmelweis  in  1847.  He  showed  that  some 
students  who  had  examined  an  ulcerating  cancer  of  the  uterus 
caused  "puerperal  fever"  and  death  in  fourteen  women. 

Here  in  America  there  was  a  celebrated  case  in  point,  which  for 
years  baffled  the  ingenuity  of  all  observers.  A  Dr.  Rutter,  of  Phil- 
adelphia, had  in  1843  forty-three  cases  of  "puerperal  fever"  in  his 
practice,  while  his  colleagues  had  none.  He  bathed,  shaved  off  his 
hair,  and  wore  a  wig.  He  stayed  ten  days  away  from  the  city  and 
did  not  take  with  him  to  his  next  patient  anything  that  he  had  worn 
or  carried  before.  She  had  an  easy  confinement,  but  she  died  from 
"  puerperal  fever."  One  of  the  greatest  authorities  on  midwifery  in 
America  in  his  time,  Chas.  D.  Meigs,  declared  in  his  work  on  "  Woman, 
her  Diseases  and  Remedies,"  that  "  such  a  fatality  was  God's  provi- 
dence." In  our  time  another  construction  has  been  put  on  this  sad 
case,  a  contemporary  of  Rutter  having  called  attention  to  his  suffering 
from  an  obstinate  mucopurulent  coryza.^  In  the  light  of  modern 
knowledge  we  can  easily  imagine  how  the  poor  doctor  touched  his 
nose  while  attending  to  his  patients  and  carried  streptococci  and 
staphylococci  into  their  genital  tracts. 

A  French  physician,  who  had  attended  eight  hundred  women  in 
childbed  without  accident,  got  a  suppurative  adenitis,  for  which  he 
wore  a  drainage-tube.  Within  three  weeks  he  had  three  cases  of 
"  puerperal  fever." 

During  the  period  of  great  morbidity  and  mortality  preceding  the 
new  era  in  Maternity  Hospital,  I  had  an  assistant  who  almost  con- 
stantly suffered  from  pustulous  eczema  of  the  hands. 

In  1889  there  was  a  paralytic  patient  in  my  service  on  Black- 
welfs  Island  who  had  a  carbuncle  on  the  sacrum.  There  were  two 
other  puerperae  in  the  same  room,  and  all  were  under  the  care  of 
the  same  nurse.  The  paralytic  patient  had  no  puerperal  disease 
whatsoever,  but  one  of  the  other  women,  who  had  been  perfectly 
well  up  to  the  eighth  day  after  her  confinement,  got  a  chill,  fol- 
lowed by  high  temperature,  and  on  examination  there  was  found 
diphtheritic  infiltration  of  the  cervix. 


698  ABNORMAL   PUERPERY. 

Putrefaction. — Semmelweis  proved  conclusively  that  the  enormous 
mortality  prevalent  in  the  Vienna  Lying-in  Hospital  was  due  to  the 
students  coming  from  the  dissecting-room  to  the  wards  in  which  preg- 
nant women  were  examined  and  delivered.  In  the  service  attended 
by  medical  students  mortality  was  three  times  as  high  as  in  the  de- 
partment in  which  midwife  pupils  were  instructed. 

A  similar  case  is  known  from  private  practice.  A  Scotch  physi- 
cian, Dr.  Renton,  and  a  friend  of  his  practised  in  the  same  small 
place.  During  a  so-called  "  epidemic  of  puerperal  fever,"  all  Renton's 
patients  remained  healthy,  while  every  one  of  his  friend's  were 
taken  sick.  The  explanation  was  that  the  former  did  not  perform  any 
autopsies,  while  the  other  doctor  did.** 

The  infection  may  originate  also  from  a  decomposing  part  of 
a  living  body.  Thus  it  is  often  due  to  retained  remnants  of  mem- 
branes or  placenta.  The  writer  once  had  a  very  conclusive  case  in 
his  service  in  Maternity  Hospital.  Two  women  were  confined  in  the 
same  room  by  two  different  assistants.  One  gave  birth  to  a  mace- 
rated fcetus  and  the  decomposed  placenta  had  to  be  manually  re- 
moved. When  the  doctor  was  through  he  disinfected  himself  with 
bichloride  of  mercury  and  examined  the  other  patient.  The  first 
woman  remained  entirely  healthy,  but  the  second  developed  one  of 
the  worst  cases  of  puerperal  infection  which  the  writer  has  ever  seen. 
Doubtless  the  doctor,  in  spite  of  his  disinfection,  brought  most  virulent 
streptococci  and  staphylococci  from  the  putrid  placenta  of  one  of  the 
women  into  the  genital  tract  of  the  other. 

Some  years  before  my  connection  with  Maternity  Hospital  a  new 
building  had  been  erected  on  Rlackwell's  Island  for  the  use  of  the 
maternity  service.  It  had  scarcely  been  opened  before  a  so-called 
"  epidemic  of  puerperal  fever"  broke  out  and  led  to  the  abandonment 
of  the  building.  The  cause  of  this  was  probably  the  manure  with 
which  the  building  had  been  surrounded  in  order  to  make  a  garden. 

Fehling^^  observed  an  epidemic  of  "puerperal  fever,"  diphtheria, 
and  erysipelas,  in  consequence  of  a  bursted  waste-pipe,  the  dirty 
water  soaking  into  the  ground  on  which  stood  the  hospital. 

Gustav  Draun"  in  1889  had  such  an  "  epidemic  of  puerperal  fever" 
in  Vienna,  that  during  a  month  nearly  eighteen  per  cent,  of  the  puer- 
perae  were  taken  sick  and  nearly  nine  per  cent.  died.  The  distin- 
guished obstetrician  attributed  the  infection  to  the  fecal  matter  from 
the  hospital  and  neighboring  barracks  being  emptied  into  a  canal  that 
flowed  past  the  hospital. 

The  immediate  contiguity  of  a  cemetery,  a  slaughter-house,  a  cess- 
pool, a  privy,  a  dunghill,  a  sewer,  a  pool  of  stagnant  water,  or  a  stable 
or  similar  places  where  organic  substances  are  undergoing  decompo- 
sition is,  therefore,  dangerous  to  a  parturient  woman. 


PUERPERAL   INFECTION.  699 

Zymotic  Diseases. — Since  the  streptococcus  of  erysipelas  is  identical 
with  that  of  puerperal  infection,  there  can  be  no  doubt  that  infectious 
material  brought  from  a  patient  suffering  from  erysipelas  to  a  puer- 
pera  can  cause  puerperal  infection  in  her. 

The  same  applies  to  diphtheria.  An  infiltration  with  a  yellowish 
mass  that  cannot  be  wiped  off,  entirely  like  what  is  called  a  diphtheritic 
condition  when  it  occurs  in  wounds  after  surgical  operations,  is  a  com- 
mon occurrence  in  puerperal  infection.  In  at  least  one  case  the  specific 
Klebs-Loffler  bacillus  diphtheriae  was  found,  and  the  patient  devel- 
oped the  usual  throat  symptoms.  The  writer  has  also  seen  the  char- 
acteristic throat  affection  follow  the  diphtheritic  condition  of  the  geni- 
tals. A  well-known  obstetrician  was,  during  an  epidemic  of  puerperal 
diphtheria  in  the  hospital  with  which  he  is  connected,  attacked  by 
diphtheritic  ophthalmia,  with  the  formation  of  a  thick  diphtheritic 
membrane  on  the  conjunctiva,  a  perforating  ulcer  of  the  cornea,  and 
the  loss  of  sight  in  the  affected  eye.  His  head  nurse  was  at  the  same 
time  attacked  by  the  same  disease,  resulting  in  the  same  condition. 
Dr.  Fallen  reported  the  case  of  simultaneous  occurrence  of  throat 
diphtheria  in  a  two-weeks-old  baby  and  puerperal  diphtheria  in  the 
genitals  of  the  mother.     Both  died. 

Scarlet  fever  may  attack  a  puerpera,  but  it  remains  scarlet  fever 
and  follows  a  course  similar  to  that  in  other  patients.  Typhoid  fever 
is  characterized  by  the  intestinal  ulcers  and  a  specific  bacillus,  and  is 
clinically  so  difi"erent  from  puerperal  infection  that  the  two  must  be 
different  morbid  entities. 

Ways  by  which  the  Infecting  Agent  enters  the  Body. — In  the  vast 
majority  of  cases  the  germs  of  infection  are  brought  mechanically  into 
the  genital  tract  of  the  pregnant,  the  parturient,  or  the  puerperal 
woman  by  the  fingers,  the  hands,  or  the  instruments  of  the  medical 
attendant,  be  it  a  doctor,  midwife,  nurse,  or  friend.  The  microbes 
may  lurk  in  one  of  the  many  lubricants  commonly  used,  such  as 
olive  oil,  lard,  butter,  vaseline,  or  cold-cream.  They  may  adhere  to 
a  sponge,  a  rag,  a  syringe  nozzle,  a  catheter,  bedclothes,  wearing 
apparel,  or  any  other  body  coming  in  contact  with  the  genitals. 

Many  go  so  far  as  to  think  that  actual  contact  is  the  only  way  of 
infection,  but  to  deny  infection  through  the  air  is  contrary  to  many 
well-established  facts.  Above  we  have  mentioned  cases  where  epi- 
demics in  hospitals  were  attributed  to  the  ground,  the  walls  of  a  build- 
ing, the  air  near  it  being  infected  with  fecal  matter,  or  waste-pipe 
water.  Now,  it  does  not  seem  at  all  likely  that  the  doctors  and  nurses 
brought  microbes  from  the  manure  around  the  new  Maternity  on 
Blackwell's  Island,  from  the  faeces  floating  in  the  canal  on  which  the 
Vienna  Hospital  was  situated,  or  from  the  ground  soaked  by  the  water 
from  the  broken  pipe.     It  is  certainly  much  easier  to  suppose  that 


700  ABNORMAL    PUERPERY. 

the  germs  of  disease  were  carried  by  tlie  air  into  tlie  buildings  where 
the  women  were  confined,  and  deposited  on  instruments,  materials, 
clothes,  or  perhaps  even  on  the  hands  of  doctors  and  nurses  or  directly 
on  the  entrance  to  the  genital  canal. 

Some  years  ago  there  was  an  epidemic  in  the  Xew  York  Infant 
Asylum,  which  was  traced  to  a  dead  rat  found  in  the  cellar.  Xow, 
the  doctors  and  nurses  had  no  business  in  the  cellar,  and  the  engineer 
never  entered  the  wards  of  the.  hospital.  The  natural  explanation  is 
that  the  microbes  developed  in  the  putrefying  body  of  the  dead  rat 
were  carried  by  the  air  from  the  cellar  along  heating  pipes  and  through 
crevices  between  boards  to  the  ward  above,  where  they  infected  the 
parturient  and  puerperal  women  directly  or  indirectly. 

Depaul^^  reported  the  following  striking  case.  A  pupil-midwife, 
while  washing  the  genitals  of  a  puerpera  affected  with  "puerperal 
fever,"  felt  an  unpleasant  sensation.  In  the  evening  she  was  taken 
sick,  and  on  the  third  day  she  died  "  with  all  the  symptoms  of  the 
most  characteristic  puerperal  fever."  The  clinical  diagnosis  was  con- 
firmed by  the  autopsy,  and  she  was  found  to  be  a  virgin  and  not  men- 
struating. In  this  case  we  have  then  not  only  infection  taking  place 
through  the  air,  but  the  place  of  entrance  being  far  from  the  genital 
wounds  in  the  healthy  lungs.  As  an  analogon  we  have  in  children 
the  mfection  starting  from  the  mouth. 

The  microbes  have  also  been  directly  caught  floating  in  the  air.^* 
The  theory  of  air-infection  within  a  limited  space  is  also  corroborated 
by  the  effects  of  sanitary  measures.  Even  before  the  new  era  in 
Maternity  Hospital  the  patients  were  always  free  from  fever  during  the 
first  week  after  a  ward  had  been  fumigated  with  sulphur.  Bush^^ 
prevented  "  puerperal  fever"  in  Berlin  by  heating  the  wards  to  60° 
Reaumur  (=  167°  Fahrenheit)  before  using  them.  In  many  hospitals 
the  rate  of  mortality  was  much  diminished  by  improved  ventilation. 
We  have  an  analogon  in  tuberculosis,  which  is  supposed  most  fre- 
quently to  be  communicated  from  one  person  to  another  by  the  sputa 
drying  and  the  bacilli  being  inhaled. 

This  infection  through  the  air  is,  however,  limited  to  quite  short 
distances.  Epidemics  in  the  old  sense  of  the  word,  when  the  air  of 
a  city  or  a  country  was  supposed  to  be  poisoned,  do  not  exist.  As 
a  celebrated  obstetrician  aptly  has  put  it,  we  might  as  well  speak 
of  an  epidemic  of  gunshot  wounds  after  a  battle.  Epidemics  are 
nowadays  rare  and  circumscribed,  and  are  ahvays  due  to  direct  trans- 
mission from  a  patient  or  from  one  of  the  foci  of  infection  spoken  of 
above. 

Autoinfection. — When  we  saw  the  effect  of  strict  antiseptic  pre- 
ventive methods,  we  were  inclined  to  throw  the  blame  for  every  case 
of  puerperal  infection  and  death  on  the  attending  doctor  or  midwife. 


PUERPERAL    INFECTION.  701 

But,  later,  abundant  evidence  has  been  adduced  to  prove  that  the 
source  of  infection  may  be  found  in  the  body  of  the  individual  herself. 
At  one  time  it  was  thought  that  this  was  true  only  of  saprophytes  and 
did  not  apply  to  pathogenic  microbes  ;  but  we  have  seen  how,  by  ad- 
vancing knowledge,  the  partition  between  pathogenic  and  non-patho- 
genic microbes  has  been  weakened.  There  is  no  longer  any  doubt  that 
staphyJococcri  and  streptococci,  as  well  as  all  other  microbes,  may  derive 
from  the  patient  herself.  Ahlfeld^'^  has  collected  twenty-three  fatal 
cases  of  puerperal  infection  in  women  upon  whom  no  vaginal  exami- 
nation had  been  made.  The  autopsy  showed  that  the  starting-point 
of  the  disease  was  a  remnant  of  the  placenta,  old  purulent  collections, 
or  latent  gonorrhoea.  Another  case  ^"  has  been  reported  where  the 
puerperal  infection  started  from  a  purulent  rhinitis,  which  gave  rise 
to  pneumonia  and  purulent  meningitis,  and  subsequently  to  metro- 
lymphangeitis.  The  only  microbes  found  were  diplococcus  lanceolatus 
and  diplococcus  pine urno nice. 

We  have  already  spoken  of  bacterium  coli  conmiune,  which  is  found 
in  every  intestine  and  urethra,  whence  it  may  invade  the  genital  tract 
and  the  peritoneal  cavity,  causing  disease  and  death. '^ 

Another  most  dangerous  microbe,  the  bacillus  emphysematosus,  is 
constantly  found  in  the  intestine,  where  it  is  not  only  harmless  but 
even  useful.  In  the  vagina  it  becomes  the  cause  of  emphysematous 
vaginitis,  but  when  it  enters  the  uterus  it  causes  the  ominous  tym- 
pania  uteri,  or  physometra.  In  general  surgery  it  is  the  cause  of  one 
of  the  most  dangerous  wound  diseases. — acute  septic  gangrene. — to 
which  in  puerperse  is  found  an  analogon  in  septic  emphysema. ^^ 

One  of  the  pus-producing  microbes,  staphylococcus  pyogenes, 
abounds  on  the  human  skin,  whence  it  may  wander  into  the  genital 
tract.  Or  it  may  arrive  there  in  another  way.  Many  women  have 
sexual  connection  up  to  the  day  of  their  confinement.  The  staphy- 
lococcus may  consequently  be  deposited  in  the  vagina  before  delivery, 
and,  starting  upward,  cause  disease. 

Since  a  woman  always  has  numerous  saprophytes  and  sometimes 
pus-producing  cocci  in  her  vagina,  these  organisms  may  be  carried 
thence  by  a  perfectly  disinfected  finger  into  the  uterus  and  cause 
infection. 

At  our  present  stage  of  knowledge  it  can  hardly  be  proved  that 
puerjDeral  disease  and  death  are  directly  attributable  to  th'3  obstetrical 
attendant ;  but,  of  course,  if  many  cases  occur  in  one  person's  prac- 
tice there  is  a  strong  presumption  that  he  personally  is  the  carrier  of 
the  infection,  and  if  it  can  be  proved  that  he  has  not  used  any  anti- 
septic precautions  a  suit  for  damages  may  perhaps  be  decided  against 
him.  Otherwise  he  can  fall  back  on  autoinfoction,  and  hope  to  estab- 
lish a  reasonable  doubt  in  the  minds  of  the  jury. 


702  ABNORMAL    PUERPERY. 

Time  of  Infection. — Infection  most  commonly  takes  place  during 
delivery,  but  it  may  occur  also  before  and  after  labor, 

§  3.  Patholog-y. — Before  it  was  known  that  puerperal  infection 
was  due  to  microbes  or  their  products,  it  was  incomprehensible  to  the 
pathologists  that  they  found  such  a  diversity  of  lesions  in  the  bodies 
of  women  who  had  died  from  what  then  was  called  "  puerperal  fever." 
In  other  diseases  they  found  the  same  lesions  in  different  cases,  such 
as  the  different  stages  of  pneumonia,  typhoid  fever,  meningitis,  etc. ; 
but  in  those  who  had  been  affected  with  "  puerperal  fever"  nearly 
every  organ  of  the  body  might  be  found  to  present  pathological 
changes. 

^DffiiTis  (Vulvitis)  and  Colpitis  (Vaginitis).^ — The  external  genitals 
may  be  the  seat  of  a  catarrhal  or  a  diphtheritic  inflammation.  In  the 
catarrhal  form  the  mucous  membrane  of  the  vulva  and  the  vagina  is 
swollen,  red,  and  secretes  a  mucopurulent  fluid  with  an  offensive  odor. 
In  the  diphtheritic  form  small  white  or  yellowish  false  membranes 
appear,  spread,  and  coalesce  until  a  more  or  less  large,  thick  patch 
is  formed  that  adheres  intimately  to  the  subjacent  tissue,  which  is 
swollen,  infiltrated  with  serum,  and  of  a  dirty  greenish  or  brown 
color. 

Endometritis  is  the  most  common  puerperal  affection.  In  ca- 
tarrhal endometritis  the  endometrium  is  red,  swollen,  covered  with  a 
purulent  fluid,  and  sometimes  studded  with  small  pustules.  The  other 
forms  are  merged  in  metritis. 

Metritis  may  assume  four  different  forms,  the  simple.,  the  dipjh- 
theritic,  the  dissecting,  and  the  putrescent. 

In  simple  metritis  the  uterus  is  enlarged.  The  wall  is  swollen, 
soft,  friable,  near  the  surface  almost  diffluent,  cherry-colored,  and 
bathed  in  a  dirty  greenish-brown  fluid.  Abscesses  may  form  in  the 
muscular  tissue,  the  pus  of  which  may  become  inspissated  or  evacu- 
ated by  rupture  of  the  wall.  In  the  cervix  are  often  found  bruises 
and  tears. 

Diphtheritic  metritis  shows  the  tissue  in  a  condition  similar  to  that 
described  under  vulvitis  and  colpitis.  It  begins,  as  a  rule,  at  the  cer- 
vix. The  writer  has,  however,  seen  it  begin  also  at  the  inner  opening 
of  the  Fallopian  tube  and  form  a  yellow,  gelatinous  layer,  extending 
to  the  peritoneum. 

Dissecting  metritis  is  a  form  that  has  been  little  noticed.  The 
writer  was  the  first  to  show  its  connection  with  puerperal  infection 
and  gave  it  its  name.  He  has  personally  had  eight  cases,  all  ex- 
amined microscopically,  demonstrated  in  medical  societies,  and  the 

^  The  words  ahhlov,  vulva,  and  aUolTu;,  inflammation  of  the  same,  have  kindly 
been  given  me  by  Dr.  Achilles  Rose.  KoATrir^f  comes  from  Ko'/.tror,  gulf,  the  Greek 
name  for  the  vagina. 


PUERPERAL   INFECTION. 


703 


Fig.  486. 


diagnosis  corroborated  by  other  examiners.    In  this  form  a  large  piece 
of  the  muscular  wall  is  gouged  out  (Fig.  486). 

In  putrescent  metritis  the  uterus  is  large,  but  the  walls  are  so  thin 
that  they  show  impressions  of  the  intestines.  The  discolored  mucous 
membrane  hangs  in  shreds  or  is  easily  moved  to  and  fro  on  the  under- 
lying tissue.  The  submucous  tissue  may  be 
changed  into  a  whitish  substance,  and  the  mus- 
cular may  be  red  and  flabby ;  but  sometimes 
the  destruction  extends  deep  into  the  muscular 
tissue,  forming  cavities  filled  with  a  chocolate- 
colored  or  black  pulp,  due  to  acute  septic  gan- 
grene, or  with  a  thinner,  ichorous  or  purulent 
fluid.  It  is  particularly  the  placental  site  that 
shows  this  deep  burrowing,  the  destructive  mi- 
crobes finding  a  favorable  soil  in  the  thrombi 
which  fill  the  veins.  In  other  cases  they  may 
follow  the  lymphatics. 

Salpingitis. — The  Fallopian  tubes  are  more 
rarely  the  way  the  inflammation  follows,  but  we 
may  find  either  catarrhal  or  purulent  salpingitis. 

Oophoritis. — The  ovaries,  on  the  contrary, 
are  frequently  inflamed.  It  may  be  a  super- 
ficial inflammation,  so-called  perioophoritis,  or 
one  in  the  interior,  parenchymatous  oophoritis. 
This  may  end  in  the  formation  of  an  abscess  or 
a  cavity  filled  with  a  brownish  ichorous  pulp 
— putrescentia  ovarii. 

Cellulitis. — The  connective  tissue  of  the 
pelvis  and  abdominal  wall  may  be  swollen,  infiltrated  with  serum, 
full  of  small  round  cells,  and  be  the  seat  of  hemorrhagic  thrombi. 
The  inflammation  may  end  in  resolution  or  in  suppuration.  In  the 
latter  case  the  abscess  may  open  into  one  of  the  liollow  organs, — 
the  bladder,  the  vagina,  or  the  rectum  ;  or  it  may  break  through  the 
skin,  especially  above  Poupart's  ligament,  or  in  Petit's  triangle,  above 
the  crest  of  the  ilium.  The  inflammation  may  even  extend  above 
the  diaphragm,  enter  the  posterior  mediastinum,  and  implicate  the 
lungs  as  interstitial  pneumonia.  Or  it  may  extend  down  the  leg, 
causing  phlegmasia  alba  dolens.  In  rare  cases  it  follows  the  round 
ligament  through  the  inguinal  canal  and  may  produce  suppurative 
adenitis  of  the  inguinal  glands.  On  account  of  this  tendency  to  spread- 
ing, Virchow  called  it  erysipelas  malif/num  internum,  a  denomination 
which  became  particularly  appropriate  when  later  it  was  discovered 
that  the  microbe  causing  the  inflammation  was  identical  with  that  of 
cutaneous  erysipelas. 


Dissecting  metritis.  Speci- 
men expelled  on  the  twenty- 
sixth  day  after  childbirth, 
consisting  of  muscular  tissue 
folded  together  so  as  to  talie 
the  shape  of  the  uterine  cav- 
ity. Length  folded,  3  inches 
(8  centimetres). 


704 


ABNORMAL    PUERPERY. 


Lymphangeitis  and  Thrombosis  of  Lymphatics.  —  The  lymphatic 
spaces  and  vessels  are  the  chief  roads  by  which  the  infection  reaches 
the  deeper  parts.  According  to  Virchow  there  is  no  lymphangeitis. 
The  lymph-vessels  become  much  enlarged,  the  lymph  stagnates  in 
them  and  becomes  inspissated  and  like  pus.  The  thrombosis  does 
not  further  the  infection,  but  is  due  to  it,  and  the  infection  extends 
through  other  branches  which  have  not  been  blocked  up.  The  lym- 
phatics from  the  vulva  and  the  lower  third  of  the  vagina  go  to  the 
superficial  inguinal  glands,  from  which  others  go  to  the  deep  inguinal 
glands,  that  again  connect  with  the  external  iliac  glands.     Thus  a 

Fig.  487. 


Lymphatics  of  the  uterus.  (Poirier.)  1,  lymphatics  from  the  body  and  fundus  of  the  uterus; 
2,  ovary  ;  3,  vagina  ;  4,  Fallopian  tube  ;  5,  lymphatics  coming  from  the  cervix ;  6,  lymphatics  going 
from  tlie  cervix  to  the  iliac  ganglia  ;  7,  lymphatics  going  from  the  body  and  fundus  to  the  lumbar 
ganglia  ;  8,  anastomoses  of  cervical  and  uterine  lymph-vessels ;  9,  small  lymph-vessel  running  in  the 
round  ligament  to  the  inguinal  glands ;  10, 11,  lymphatics  from  the  tube  which  empty  into  the  large 
lymph-vessels  from  the  body  of  the  uterus  ;  12,  ovarian  ligament. 


wound  on  the  labium  majus  may  become  the  starting-point  of  a 
general  peritonitis. 

The  lymphatics  from  the  upper  two-thirds  of  the  vagina  and  the 
cervix  go  to  the  internal  iliac  and  the  sacral  glands.  The  uterus 
itself  is  a  net-work  of  lymph-spaces  and  lymph-vessels,  which,  finally, 
lead  to  the  lumbar  glands  (Fig.  487). 

While  the  lymph-vessels  normally  are  so  small  that  they  cannot 
be  seen  until  they  are  injected  with  mercury,  they  become  as  thick 
as  goose-quills  when  they  are  thrombosed,  and  they  may  form  prom- 
inences on  the  surface  of  the  uterus  as  large  as  cherries  and  filled 


PUERrERAL   INFECTION. 


705 


with  a  pus-like  fluid  (Fig.  488).     From  the  finer  lymph-vessels  the 
infection  extends  to  the  surrounding  connective  tissue. 

Peritonitis. — The  inflammation  of  the  peritoneum  is  the  most 
common  finding  in  the  severer  cases  of  puerperal  infection.  It  may 
be  limited  to  the  pelvis — locals  ov  pelvic^  peritonitis — or  spread  more  or 
less  over  the  abdomen — diffuse  peritonitis.  The  inflammation  may  be 
adhesive  or  exudative.  In  the  adhesive  form  the  intestines  are  glued 
together  or  to  other  organs  with  a  semi-solid  plastic  lymph.  In  the 
exudative  form  there  is  a  more  or  less  large  amount  of  free  fluid, 
which  may  be  serous,  fibrinous,  or  purulent ;  or  it  may  be  ichorous, 
brownish,  and  offensive.    Sometimes  it  is  much  like  milk,  and  contains 

Fig.  488. 


Lymphangeitis  and  lymphothrombosis  of  uterus.     (Spiegelberg.) 

large  clots  like  curd.  There  may  be  as  much  as  one  or  two  quarts  of 
it.  The  peritoneum  is  injected  and  in  places  the  endothelium  has  been 
lost.  The  abdomen  is  swollen  in  consequence  of  the  formation  of  gases 
in  and  the  paralysis  of  the  intestine.  In  most  cases  the  infection 
starts  in  the  endometrium  and  spreads  through  the  lymphatics. 

Pleurisy  and  Pericarditis. — From  the  peritoneum  the  microbes 
easily  spread  through  the  stomata  of  the  diaphragm  to  the  pleura  and 
the  pericardium.  The  membranes  become  red,  swollen,  and  covered 
with  false  membranes,  and  the  cavities  in  their  interior  contain  a  sero- 
purulent  fluid. 

Phlebitis. — Less  frequently  than  the  lymphatics,  the  veins  are  the 
road  invaded  by  the  microbes.  When  the  muscular  tissue  does  not 
contract  with  normal  strength,  thrombi  form  in  the  veins  of  the  pla- 
cental site  and  sinuses  in  the  uterine  wall.  As  we  have  seen  above, 
such  thrombi  furnish  a  favorable  soil  for  the  propagation  and  penetra- 
tion of  microbes.  The  thrombosis  may  extend  into  the  broad  liga- 
ments and  to  the  upper  part  of  the  thigh,  where  it  leads  to  phlegmasia 
alba  dolens. 

45 


706  ABNORMAL   PUERPERY. 

The  thrombus  may  become  disintegrated,  and  detritus  from  it  may 
be  carried  by  tlie  blood  current  to  the  heart — the  condition  known  as 
pycemia.  In  this  way  nearly  all  organs  of  the  body  may  secondarily 
become  infected.  In  the  lungs  these  infarctions  give  rise  to  pneumonia 
and  pulmonary  abscesses.  In  the  posterior  part  of  these  organs  is 
often  found  hypostatic  pneumonia.  In  the  liver  may  be  found  hepa- 
titis and  abscesses.  The  kidneys  also  become  inflamed  and  the  seat 
of  abscesses.  In  the  more  chronic  cases  there  may  be  amyloid  de- 
generation of  the  kidneys.  The  abundant  adipose  connective  tissue 
surrounding  the  kidneys  is  apt  to  become  inflamed  and  form  a  peri- 
nephritic  abscess.  The  spleen  is  large  and  soft,  and  may  contain 
infarctions,  but  these  rarely  suppurate.  The  mucous  membrane  of 
the  intestine  is  swollen,  but  does  not  ulcerate.  The  heart  is  frequently 
the  seat  of  pericarditis,  endocarditis,  which  mostly  is  ulcerous,  and 
myocarditis.  The  eyes  may  be  destroyed  by  panophthalmia.  The 
brain  and  its  meninges  are  rarely  inflamed,  except  in  ulcerous  endo- 
carditis. The  mammary  glands,  the  thyroid  body,  the  parotid,  the 
tonsils,  may  all  become  inflamed  and  form  abscesses.  In  the  bladder 
are  sometimes  found  ulcerations.  The  articulations,  especially  the 
knee,  the  elbow,  and  the  shoulder,  may  suppurate  and  become  anky- 
losed.  The  skin  is  the  seat  of  erythematous,  erysipelatous,  vesicular, 
or  pustular  eruptions.  The  subcutaneous  and  intermuscular  connec- 
tive tissue  may  become  inflamed,  and  form  large  abscesses  and  shreds 
of  necrotic  tissue. 

A  piece  of  a  thrombus  may  be  torn  off,  form  an  embolus,  and 
cause  paralysis  or  heart-clot.  In  favorable  cases  the  thrombus  may 
be  tunnelled  and  circulation  re-established,  or  it  may  become  organ- 
ized and  form  a  permanent  plug  in  the  vein. 

The  disease  known  as  phlegmasia  alba  dolens  may  be  a  phlebitis  or 
cellulitis,  or  both  combined.  It  begins  always  at  the  upper  part  of 
the  thigh,  and  the  name  should  not  be  used  to  designate  a  simple 
marantic  thrombosis  starting  in  the  veins  of  the  calf  and  the  lower 
part  of  the  thigh.  Phlegmasia  alba  may  be  a  continuation  of  phle- 
bitis of  the  ovarian  and  iliac  veins.  Sometimes  the  vein  is  first 
affected  by  thrombosis,  which  leads  to  phlebitis  and  periphlebitis.  In 
other  cases  the  inflammation  starts  in  the  connective  tissues,  and  the 
vein  becomes  secondarily  implicated.  The  thrombi  may  undergo  all 
the  changes  described  above.  In  the  phlebitic  form  one  or  more  veins 
form  strings,  below  which  the  leg  is  swollen. 

In  the  cellulitic  form  the  skin  is  white  or  pink,  tense,  and  hard. 
One  or  both  legs  swell.  The  epidermis  may  be  lifted  by  a  serous 
exudation,  forming  large  vesicles.  The  inguinal  glands  swell.  The 
connective  tissue  may  become  necrotic  and  bathed  in  pus,  but  this 
pernicious  form  is  rare. 


PUERPERAL   INFECTION.  707 

AcuTEST  Septicemia. — In  the  worst  cases  of  puerperal  infection  all 
these  inflammations  hardly  have  time  to  form,  before  the  patient  suc- 
cumbs to  the  violence  of  the  attack.  Still,  there  are  traces  of  lym- 
phatic thrombosis,  phlebitis  of  the  uterus,  and  svi^elling  of  the  connec- 
tive tissue.  The  liver,  spleen,  and  kidneys  are  large,  soft,  friable,  and 
their  cells  show  cloudy  swelling.  There  is  a  little  reddish  fluid  in  the 
different  cavities.  Sometimes  gas  is  formed,  especially  in  the  liver — 
foaming  liver — and  in  the  uterus — tympania  uteri.  This  gas  produc- 
tion is  generally  due  to  the  bacillus  aerogenes  capsulatus.  The  blood 
is  dark,  thin,  and  has  lost  most  of  its  coagulability. 

§  4.  Symptoms,  Diagnosis,  and  Prognosis.  —  In  particularly 
well-conducted  institutions  bacteriological  examinations  are  made  daily 
during  the  puerperium,  and  thus  it  may  be  known  what  kind  of  infec- 
tion is  present,  and  a  prognosis  founded  thereon.  But  most  phy- 
sicians have  to  go  by  the  clinical  features  of  the  case.  Three  points 
are  of  great  importance  in  this  respect — the  time  of  the  beginning  of 
the  disease,  the  fever,  and  the  mental  condition  of  the  patient.  If  the 
infection  begins  early,  perhaps  within  a  few  hours,  if  the  temperature 
rises  much,  the  pulse  becomes  rapid,  and  the  patient  becomes  deliri- 
ous or  somnolent,  the  case  is  serious.  But  even  under  favorable  cir- 
cumstances the  prognosis  should  always  be  guarded,  for  an  infection 
caused  by  saprophytes,  or  a  condition  that  is  not  infectious  at  all,  as  a 
marantic  thrombosis  of  a  vein  in  the  calf,  may,  exceptionally,  end  in 
serious  infection  and  death. 

Some  groups  of  cases  are  so  well  marked  by  characteristic  symp- 
toms that  they  are  easily  described  and  easily  recognized.  Thus, 
there  is  a  group  of  localized  infections  in  which  the  disease  remains 
limited  to  the  genital  tract  and  hardly  affects  the  general  condition  of 
the  patient.  In  such  a  case  the  prognosis  is  favorable.  Then  there 
is  a  lymphatic  form,  in  which  the  disease  begins  early  and  spreads 
rapidly  to  the  serous  membranes — the  peritoneum,  the  pleura,  and 
the  pericardium.  This  is  very  grave.  Next,  there  is  a.  phlebitic  form, 
which  begins  later,  progresses  more  slowly  than  the  lymphatic,  is  ac- 
companied by  repeated  chills,  and  causes  metastases  in  remote  organs. 
Here  also  the  prognosis  is  at  least  serious.  Finally,  there  are  cases 
of  acutest  septicaemia  in  which  the  patient  dies  before  localizations  are 
developed. 

But  the  cases  cannot  all  be  pressed  into  these  groups  ;  sometimes 
two  such  groups,  as  the  lymphatic  and  phlebitic,  are  combined  ;  and 
often  one  passes  into  the  other.  The  writer  prefers,  therefore,  to  main- 
tain the  division  based  on  the  organs  invaded,  and  to  add  remarks  on 
diagnosis  and  prognosis  as  he  progresses  from  one  organ  to  the  other. 

tEdceitis  and  Colpitis. — In  the  catarrhal  form  micturition  causes 
smarting. 


708  ABNORMAL    PUERPERY. 

In  the  ulcerative  form  there  is  a  little  fever,  and  often  the  lochia 
become  fetid.  The  labia  are  swollen,  red,  and  sensitive.  Micturition 
is  painful  and  sometimes  there  is  retention  of  urine.  The  ulcers  are 
slow  to  heal,  three  w-eeks  elapsing,  perhaps,  before  recovery. 

The  diphtheritic  form  is  much  more  serious.  It  begins  often  with 
a  chill,  and  the  temperature  may  reach  107°  F.  This  fever  begins 
generally  from  two  to  four  days  after  delivery.  It  has  no  typical  tem- 
perature-curve, except  that  there  usually  is  a  rise  towards  evening. 
The  pulse  is  rapid  and  weak  and  the  respiration  accelerated.  The 
patient  has  no  appetite.  The  tongue  is  coated,  the  bowels  are  often 
loose,  and  the  woman  frequently  suffers  from  nausea  and  vomiting. 

As  a  rule,  the  uterus  is  implicated.  It  becomes  large  and  tender, 
and  the  lochia  become  scanty,  grayish,  and  offensive.  The  secretion 
of  milk  either  does  not  become  estabhshed  or  it  ceases.  The  patient 
complains  of  pains  in  the  hypogastric  region,  sometimes  extending 
dow^n  the  legs.  She  has  severe  headache,  and  soon  she  becomes 
stupid  and  delirious.  These  signs  of  a  general  affection  may  precede 
the  appearance  of  the  patches.  For  several  days  new  patches  are 
formed,  and  the  old  ulcers  spread.  From  the  time  the  infiltration 
ceases  until  the  scabs  formed  by  the  treatment  fall  off  and  the  sores 
heal,  about  a  week  elapses. 

Erythema  or  erysipelas  may  start  from  the  swollen  labia  and 
extend  more  or  less  over  the  body.  Sometimes  the  vulva  or  vagina 
becomes  gangrenous.  The  cicatrices  which  follow  the  ulcers  may 
cause  considerable  narrowing  and  shortening  of  the  vagina. 

Diagnosis. — With  a  little  care  diphtheritic  sores  are  easily  dis- 
tinguished from  pus-covered  tears.  In  the  former  there  is  an  adhe- 
rent yellow  infiltration  ;  in  the  latter  the  pus  is  easily  wiped  off. 
Plain  tears,  when  properly  attended  to,  cause  neither  local  nor  general 
disturbance.     The  diphtheritic  sores  spread  with  a  scalloped  outline. 

Prognosis. — In  the  catarrhal  and  plain  ulcerative  form  of  aedoeitis 
and  colpitis  the  prognosis  is  good  ;  in  the  diphtheritic  form  there  is 
a  considerable  mortality. 

Endometritis  and  Metritis. — Simple  endometritis  and  metritis  often 
begin  with  a  chilly  sensation  and  are  accompanied  by  moderate  fever. 
The  patient  has  some  pain  in  the  hypogastric  region  and  severe  after- 
pains,  no  appetite,  and  a  coated  tongue.  The  lochial  discharge  is 
mostly  fetid,  continues  red  longer  than  usual,  or  becomes  red  again 
after  having  been  yellow.  The  uterus  is  enlarged  and  tender  on 
pressure.  As  to  the  diphtheritic  form,  its  symptoms  are  the  same  as 
those  of  diphtheritic  aedoeitis  and  colpitis.  The  diagnosis  of  strepto- 
coccic endometritis  is  based  on  bacteriology.  If  it  is  known  that 
parts  of  the  placenta  or  membranes  have  been  retained,  the  presence 
of  streptococci  is  likely.     A  fetid  discharge  is  not  characteristic.     It 


PUERPERAL   INFECTION.  709 

may  be  absent  with  dangerous  infection,  and  it  may  only  be  due  to 
saprophytes  in  the  uterus  or  the  vagina.  In  this  respect  the  French 
alhteration  "  Ce  qui  pue  ne  tue  pas"  (What  stinks  does  not  kill)  has 
some  foundation.  Dissecting  metritis  is  characterized  by  a  protracted 
purulent  discharge.  The  putrescent  form  gives  the  symptoms  of  the 
severest  diphtheritic  cases,  and  is  accompanied  by  a  particularly 
offensive  discharge. 

Prognosis. — In  benign  endometritis  and  simple  metritis  the  prog- 
nosis is  good.  The  disease  lasts  a  week  or  two.  The  diphtheritic 
form  often  ends  in  death.  The  dissecting  form  has  a  better  prognosis. 
Of  the  writer's  eight  cases  only  one  died,  and  in  that  death  was  due 
to  rupture  of  the  uterus  brought  on  by  an  error  in  washing  out  the 
uterus.  Of  all  fourteen  cases  known,  three  ended  fatally.  The  pu- 
trescent form  is  nearly  ahvays  fatal. 

Salpingitis  and  Oophoritis. — The  inflammation  of  the  tubes  and 
ovaries  is  only  found  combined  with  endometritis  or  peritonitis,  and 
the  symptoms  become  merged  in  those  of  these  affections. 

Parametritis  (Cellulitis  of  the  Pelvis). — The  inflammation  of  the 
connective  tissue  of  the  parametrium  and  the  broad  ligaments  begins 
generally  on  the  fourth  day,  if  labor  has  been  normal.  If,  on  the 
other  hand,  it  has  been  protracted  or  feverish,  the  parametritis  may 
begin  as  early  as  the  second  day.  It  rarely  begins  as  late  as  the 
eighth  day  or  still  later,  and  then  generally  after  some  interference 
with  the  endometrium  or  the  cervix.  This  is  technically  called  late 
infection.  It  begins  with  a  chill  or  chilly  sensation,  anorexia,  thirst, 
weakness,  sensation  of  heat,  and  a  bruised  feeling  in  the  limbs.  The 
temperature  rises.  Pulse  and  respiration  become  more  frequent. 
The  patient  complains  of  pain  at  the  side  of  the  uterus,  and  on  bi- 
manual examination  we  find  the  vault  of  the  vagina  tender  and  a 
swelling  extending  from  it  in  the  direction  of  the  iliac  fossa.  When 
the  swelling  increases  it  pushes  the  uterus  over  to  the  opposite  side. 
As  a  rule,  only  one  side  is  affected.  The  uterus  is  hardly  movable. 
Severe  neuralgic  pain  may  shoot  down  the  legs  or  up  to  the  lumbar 
region,  which  may  be  due  to  pressure  on  the  nerves  or  their  partici- 
pation in  the  inflammatory  process.  If  the  inflammation  extends  to 
the  iliac  fossa,  the  corresponding  extremity  is  drawn  up  and  adducted, 
so  that  the  knee  lies  on  the  other  leg.  The  extremity  swells.  Some- 
times thrombi  may  be  felt  in  the  veins  of  Scarpa's  triangle,  the  pop- 
liteal space,  or  the  calf. 

Generally,  the  inflammation  of  the  connective  tissue  ends  in  reso- 
lution, but  it  may  end  also  in  suppuration.  If  the  fever  lasts  over 
three  weeks,  it  is  probably  due  to  suppuration.  Sometimes  there  is  a 
free  interval  of  a  week  or  two,  and  then  fever  begins  again.  The 
patient  has  repeated  chills,  mostly  in  the  afternoon,  while  there  is  a 


710  ABNORMAL   PUERPERY. 

remission  in  the  morning.  The  pulse  becomes  smaller  and  more  rapid. 
The  woman  loses  her  appetite.  The  swelling  becomes  softer  and 
more  sensitive,  and  finally  fluctuation  may  be  felt.  The  abscess  may 
open  into  the  bladder,  when  pus  will  be  evacuated  with  the  urine.  Or 
it  may  open  into  the  rectum,  when  it  can  be  seen  in  the  stools  and 
is  accompanied  by  diarrhoea.  Or  it  may  break  into  the  vagina.  In 
these  cases  the  fever  ceases  and  the  opening  usually  closes.  The  ab- 
scess may  also  extend  to  more  remote  parts  and  break  over  Poupart's 
ligament,  over  the  middle  of  the  crest  of  the  ilium,  or  on  the  back. 
Very  rarely  it  ruptures  into  the  peritoneal  cavity  and  causes  then 
acute  peritonitis  and  death. 

Diagnosis. — It  may  be  difficult  to  decide  whether  an  inflammation 
starts  in  the  connective  tissue  or  in  the  peritoneal  cavity.  Parametritis 
nearly  always  starts  from  a  tear  in  the  cervix.  The  swelling  is  found 
on  one  or  both  sides  of  the  uterus,  not  behind,  except  as  a  narrow 
bridge  connecting  the  two  sides.  When  it  reaches  the  pelvic  wall  it 
lies  close  up  to  the  bone,  while  in  peritonitis  the  tips  of  the  fingers  can 
be  inserted  between  it  and  the  pelvic  bones.  A  parametritis  often 
spreads  downward  along  the  vagina,  while  peritonitis  can  only  extend 
to  the  other  side  or  upward,  and  as  a  rule  it  fills  Douglas's  pouch  and 
pushes  the  uterus  forward. 

Prognosis. — Generally  the  inflammation  ends  in  resolution  in  two 
weeks.  If  an  abscess  forms,  the  prognosis  is  less  good,  both  as  to  life 
and  time,  but  with  proper  care  even  that  generally  ends  in  recovery. 
If  the  suppuration  is  allowed  to  spread  far,  the  patient's  strength  may 
be  exhausted  by  the  protracted  fever  and  loss  of  substance  through 
sinuous  fistulous  tracts.  Rupture  into  the  peritoneal  cavity  is  fatal, 
unless  a  successful  laparotomy  can  be  promptly  performed.  If  cellu- 
litis forms  part  of  a  general  infection,  the  prognosis  is  very  doubtful. 

Lymphangeitis  and  Lymphothrombosis. — Lymphangeitis  may  start 
from  the  vulva  and  lower  part  of  the  vagina.  Ordinarily  it  is  an  af- 
fection of  little  importance.  There  is  slight  fever.  Some  red  streaks 
may  be  seen  on  the  skin.  The  process  is  arrested  in  the  superficial 
inguinal  glands,  Avhich  rarely  suppurate.  Exceptionally,  the  deeper 
inguinal  glands  are  impKcated,  and  then  peritonitis  may  follow. 

The  lymph-vessels  of  the  uterus  are  the  most  common  road  of 
general  puerperal  infection,  but  the  thrombosis  and  the  infection 
may  also  remain  local.  The  patient  has  the  fever-symptoms.  The 
uterus  is  enlarged  and  tender,  especially  near  the  cornua.  There 
may  be  a  little  vomiting  and  some  tympanites.     The  pulse  is  full. 

Diagnosis. — Uterine  lymphothrombosis  diff"ers  from  cellulitis  and 
local  lieritonitis  by  the  absence  of  swelling  at  the  vaginal  roof,  and 
from  diffuse  peritonitis  by  the  limitation  of  swelling  to  the  lower  part 
of  the  abdomen,  the  full  pulse,  and  the  absence  of  green  vomit. 


PUERPERAL   INFECTION.  711 

Peritonitis. — The  inflammation  of  tlie  peritoneum  may  be  local, 
that  is,  limited  to  the  pelvis,  or  diffuse,  extending  more  or  less  over  the 
w^hole  abdomen. 

Like  the  other  inflammations,  local  jperitonitis  begins  with  a  chill, 
but  this  is  much  severer  and  more  protracted,  lasting  from  ten  to 
twenty  minutes.  There  is  a  peculiar  intense  pain  in  the  lower  part  of 
the  abdomen,  which  is  extremely  sensitive  to  touch.  The  temperature 
suddenly  rises  to  103°  or  104°  F.  The  pulse  beats  from  100  to  120 
times  per  minute,  and  is  small  and  hard.  Respiration  is  rapid.  The 
fever  is  continuous,  ordinarily  with  an  exacerbation  in  the  evening. 
The  patient  has  no  appetite,  but  suffers  from  unquenchable  thirst. 
The  tongue  is  coated.  The  bowels  are  in  the  beginning  constipated, 
later  loose.  There  is  in  general  some  vomiting  of  food,  mucus,  and 
bile,  and  sometimes  moderate  hiccup.  The  lower  part  of  the  abdo- 
men is  distended.  In  order  to  lessen  the  tension  the  patient  lies  on 
her  back  and  draAvs  her  knees  up.  The  milk  secretion  is  normal  or 
scant.  The  lochia  are  less  in  amount,  of  a  dirty  color,  and  often  of 
offensive  odor. 

In  the  course  of  a  week  or  two  a  distinct  tumor  is  felt  occupying 
the  pelvis  and  the  nearest  part  of  the  abdomen.  It  is  formed  by  an 
exudation  walled  off  by  the  agglutinated  intestine,  omentum,  uterus, 
and  appendages.  The  exudation  pushes  the  vaginal  vault  down  so 
that  the  cervix  disappears,  and  cervix  and  body  of  the  uterus  form 
together  one  pear-shaped  body  without  a  line  of  demarcation  between 
the  two.  The  abdominal  surface  of  the  tumor  is  uneven,  and  it  offers 
a  different  degree  of  resistance  in  different  parts.  Sometimes,  on  light 
pressure,  we  have  a  sensation  similar  to  that  in  pressing  a  snowball. 
This  is  due  to  fresh  adhesions  rupturing  under  the  pressure. 

The  inflammation  commonly  ends  in  resolution,  the  fluid  being 
absorbed,  and  the  hard  swelling  subsiding  in  the  course  of  two  or 
three  weeks.     Pain  and  fever  cease. 

But  the  exudation  may  also  become  purulent.  Then  the  fever 
continues,  and  the  patient  has  repeated  chills.  The  swelling  becomes 
boggy,  and  sometimes  fluctuation  may  be  felt  in  the  vagina.  The 
abscess  may  open  into  one  of  the  hollow  organs,  especially  the  vagina. 
If  it  progresses  towards  the  bladder  or  the  rectum,  there  may  be 
dysuria  or  tenesmus.  When  the  abscess  breaks,  a  large  amount  of 
offensive  pus  and  grunious  substance  is  evacuated.  Pain  and  fever 
may  cease.  The  opening  may  close,  but  sometimes  the  abscess  refills, 
or  if  there  are  several  separate  pus  collections,  the  process  may  be 
tedious  and  exhaust  the  patient.  The  pus  may  also  follow  the  out- 
side of  the  vagina  and  breakthrough  the  skin  in  the  ischiorectal  fossa. 
Sometimes  the  bowel  or  the  bladder  becomes  inflamed,  or  a  pyelo- 
nephritis develops. 


712  ABNORMAL    PUERPERY. 

Prognosis. — As  a  rule,  local  peritonitis  ends  in  recoverj'',  but  it 
may  become  diifuse  or  exhaust  the  patient's  strength.  As  to  com- 
plete restoration  to  health,  the  prognosis  must  be  guarded.  The 
disease  is  apt  to  return.  Often  chronic  salpingitis  and  oophoritis 
remain  and  make  the  patient  more  or  less  of  an  invalid.  It  is  a 
frequent  cause  of  sterility,  and  if  the  patient  becomes  pregnant  again, 
there  is  a  tendency  to  a  similar  attack. 

Diffuse  2^^ritonitis  has  symptoms  like  the  local,  but  much  inten- 
sified. It  begins  commonly  from  two  to  four  days  after  delivery,  but 
sometimes  immediately  after  parturition.  The  chill  lasts  from  half 
an  hour  to  several  hours.  The  pain  is  excruciating  and  spreads  all 
over  the  abdomen.  The  pulse  is  small  and  beats  from  120  to  140  per 
minute.  The  temperature  is  104°  F.  or  more.  The  respiration  ranges 
from  26  to  56,  and  it  is  shallow  on  account  of  the  pain  produced  by 
the  movement  of  the  diaphragm  and  on  account  of  the  compression 
of  the  lungs  by  the  intestine  inflated  with  gas.  The  patient  lies  on 
her  back.  She  shuns  every  movement  and  dreads  every  approach. 
Even  the  weight  of  the  bedclothes  may  be  intolerable.  Her  face  ex- 
presses the  greatest  anxiety  and  pain.  Her  features  are  pinched,  the 
corners  of  her  mouth  drawn  down ;  the  eyes  sink  deep  into  their 
sockets,  and  are  surrounded  by  black  rings.  The  skin  is  pale,  the 
tongue  dry,  red  at  the  point  and  edges,  and  brown  in  the  middle. 
The  thirst  is  unquenchable.  The  patient  vomits  continuously,  and 
the  vomit  soon  gets  a  characteristic  appearance,  like  chopped  spin- 
ach. Often  the  patient  has  diarrhoea,  and  sometimes  her  sufferings 
are  intensified  by  constant  hiccup. 

The  urine  is  scant  and  often  contains  albumin.  Frequently  there 
is  retention.  The  milk-secretion  soon  ceases.  The  lochia  diminish 
and  are  often  offensive  or  disappear. 

The  abdomen  is  enormously  distended.  The  percussion  tone  is 
tympanitic  in  front,  dull  on  the  dependent  parts.  The  pectoral  organs 
are  pushed  up.  The  heart  is  weak  and  becomes  paralyzed  by  absorp- 
tion of  toxines. 

The  patient  suffers  from  insomnia,  and  at  the  same  time  she  is  in  a 
somnolent  condition.  She  is  slow  to  answer  questions  or  is  delirious, 
but  sometimes  the  intellect  remains  clear  to  the  last.  At  times  she 
starts  up  as  if  horrified  by  dreams,  and  looks  around  in  dismay.  After 
three  or  four  days  the  aspect  changes.  The  pain  ceases,  the  patient 
thinks  she  is  well,  but  death  ends  the  painful  scene  between  the 
seventh  and  tenth  days.  Sometimes  there  is  a  relapse  when  the 
inflammation  reaches  the  stomach. 

Prognosis. — Diffuse  peritonitis  is  one  of  the  most  dangerous  forms 
of  puerperal  infection,  but  the  patient  may  recover. 

Favorable  signs  are  subsidence  of  the  fever,  diminution  of  tym- 


PUERPERAL    INFECTION.  713 

panites,  cessation  of  vomiting,  freedom  from  pain,  return  of  appetite, 
clearness  of  mind,  and  cheerfulness.  Unfavorable  signs  are  an  irreg- 
ular pulse  or  one  beating  more  than  140  per  minute ;  a  temperature 
over  104°  F. ;  a  laborious  respiration,  over  40  ;  colliquative  diarrhoea ; 
profuse  perspiration  ;  cold,  clammy  extremities ;  the  appearance  of 
red  blotches  on  the  skin  ;  and  cessation  of  pain,  while  the  tympanites 
remains  the  same. 

Death  occurs  generally  after  nine  or  ten  days,  but  if  an  abscess 
ruptures  into  the  peritoneum  it  follows  in  a  day  or  two. 

The  exudation  may  be  reabsorbed  or  encysted  so  as  to  form  local- 
ized foci.     Often  the  patient,  if  she  recovers,  remains  invalidated. 

Pleurisy. — Pleurisy  may  appear  as  solitary  localization,  but  is  most 
frequently  a  corollary  to  peritonitis  or  phlebitis,  and  is  then  easily  over- 
looked, inasmuch  as  the  patient's  condition  does  not  authorize  a 
thorough  physical  examination.  When  pleurisy  joins  peritonitis  or 
phlebitis,  there  may  be  an  increase  in  fever,  a  new  chill,  or  increased 
embarrassment  of  respiration. 

Prognosis. — Pleurisy  is  a  very  serious  form  of  puerperal  infection. 
Ordinarily  death  occurs  before  the  end  of  the  second  week. 

Pneumonia. — Pneumonia  may  appear  as  hypostatic  pneumonia  in 
the  posterior  parts  of  the  lungs  or  in  disseminated  foci  anywhere.  It 
is  generally  combined  with  pleurisy.  The  usual  symptoms — cough, 
pain  in  the  chest,  dyspnoea, and  bloody  expectoration — maybe  absent, 
when  the  localization  can  be  recognized  only  by  the  stethoscopic  signs 
— crepitant  rales,  bronchial  respiration,  and  dull  or  flat  percussion. 

Prognosis. — Pneumonia  is  a  dangerous  complication. 

Pericarditis. — Pericarditis  may  be  propagated  through  lymph- 
vessels  of  the  diaphragm  from  peritonitis,  or  it  may  be  due  to  emboli 
from  phlebitis.  The  symptoms  are  usually  merged  in  those  of  other 
inflammations,  but  friction  sound  may  reveal  the  presence  of  false 
membranes,  or  an  increased  dulness  may  show  that  there  is  a  fluid 
exudation  around  the  heart. 

Phlegmasia  Alba  Dolens. — Phlegmasia  begins,  as  a  rule,  in  the  sec- 
ond week  of  the  puerperium.  There  may  be  premonitory  symptoms, 
such  as  anorexia,  a  bad  taste,  eructations,  or  a  coated  tongue.  The 
inflammation  is  often  ushered  in  by  a  chill.  The  patient  is  feverish, 
and  the  urine  concentrated.  The  limb  begins  to  swell  from  above,  the 
upper  part  of  the  thigh  being  first  affected,  but  from  there  the  oedema 
may  extend  all  over  the  limb,  and  later  the  other  side  may  become 
swollen,  too,  either  independently  or  through  extension  of  the  throm- 
bosis to  the  vena  cava  inferior.  The  skin  becomes  tense,  of  a  white 
or  pink  color,  and  the  patient  complains  of  severe  pain  and  heaviness 
of  the  leg.  The  epidermis  may  become  raised  in  vesicles.  In  the 
phlebitic  form  the  veins  may  be  felt  as  hard  strings.     The  disease 


714  ABNORMAL   PUERPERY. 

usually  ends  in  resolution  in  from  three  to  six  weeks.  It  may  end 
also  in  suppuration,  and  abscesses  may  break  on  the  skin,  and  still 
the  patient  may  recover.  It  may  also  end  in  gangrene  or  septicaemia 
and  death. 

Sometimes  the  skin  has  a  dark-purple  color,  which  variety  is  called 
phlegmasia  ccerulea  dolens.  It  is  due  to  the  thrombosis  and  inflamma- 
tion of  the  deep  veins  of  the  thigh. 

The  thrombus  is  generally  reabsorbed,  but  may  become  infected 
and  give  rise  to  all  the  above-described  metastases. 

The  cellulitic  form  is  a  more  violent  type.  It  is  accompanied  by 
high  fever  and  intense  pain.  The  skin  becomes  red,  pus-filled  blebs 
may  raise  the  epidermis,  the  connective  tissue  suppurates  and  becomes 
necrotic.  It  may  be  expelled  in  large  shreds  and  the  openings  heal, 
but  there  is  great  danger  of  the  patient  becoming  exhausted  by  the 
protracted  suppuration,  or  gangrene  or  general  septicaemia  may  develop 
and  end  her  life. 

Phlebitis. — Phlebitis  may  develop  in  the  lower  extremity  or  in  the 
uterus. 

Isolated  jMebitis  of  the  leg  is  not  rare  or  grave,  and  will  be  eluci- 
dated later.  Exceptionally  the  thrombus  may  become  infected  and 
give  rise  to  general  infection. 

Uterine  Phlebitis,  or  3£etrojMebitis. — The  veins  of  the  uterus  may 
become  the  seat  of  a  common  thrombosis,  which  may  extend  to  the 
iliac  veins  and  the  vena  cava  or  to  those  of  the  thigh,  where  it  causes 
phlegmasia  alba  dolens.  This  benign  thrombosis  ends  in  resolution. 
But  if  the  thrombi  become  infected,  we  have  one  of  the  most  danger- 
ous forms  of  puerperal  infection,  which  leads  to  pyaemia. 

Uterine  phlebitis  develops  later  than  peritonitis.  As  a  rule,  the 
initial  chill  does  not  come  before  the  fifth,  sixth,  or  seventh  day.  It  is 
severe  and  protracted,  and  is  followed  by  similar  attacks  at  irregular 
intervals.  They  are  due  to  the  entrance  of  microbes  or  their  products 
into  the  blood.  While  the  patient  shakes  with  a  subjective  sensation 
of  cold  the  thermometer  shows  a  temperature  ranging  from  104°  to 
108°  F.  The  pulse  beats  from  140  to  160.  The  respiration  is  as  fre- 
quent as  from  36  to  56  per  minute.  Rarely  the  chill  is  represented 
only  by  a  slighter  chilly  sensation.  After  the  chills,  especially  the  first, 
the  patient  feels  better,  temperature  falls  to  100°  or  101°,  pulse  and 
respiration  become  much  less  frequent.  Entirely  different  from  what 
we  have  seen  in  peritonitis,  in  uterine  phlebitis  there  is  no  pain,  little 
tenderness,  and  no  tympanites. 

Another  chief  feature  of  metrophlebitis  is  the  occurrence  of  metas- 
tases due  to  the  localization  of  the  microbes  in  different  organs.  For 
each  new  localization  there  is  a  new  chill,  until  the  fever  approaches 
the  continuous  type  with  exacerbations.     The  skin  becomes  yellowish, 


PUERPERAL    INFECTION.  715 

or  a  true  jaundice  develops,  the  features  are  pinched,  the  tongue 
coated,  often  the  breath  has  a  peculiar  nauseous  smell  designated  as 
"  sweet."  The  patient  has  no  appetite,  but  great  thirst,  headache, 
insomnia,  sometimes  diarrhoea,  less  frequently  vomiting.  The  urine  is 
scant  and  nearly  always  contains  albumin. 

In  mild  cases  there  may  be  only  two  or  three  chills  in  the  course  of 
a  week,  and  the  disease  may  end  in  recovery  without  localizations.  In 
the  severe  cases  the  secondary  infection  appears  first  in  the  lungs,  then 
in  the  pleura,  the  heart,  the  liver,  the  kidneys,  the  spleen,  the  intestine, 
the  meninges,  the  brain,  the  eyes,  the  muscle-sheaths,  especially  those 
of  the  forearm,  the  articulations,  the  skin,  and  the  connective  tissue. 
Late  uterine  hemorrhage  is  rare,  but  very  dangerous.  Pneumonia, 
pleurisy,  and  pericarditis  have  already  been  noticed  in  connection  with 
peritonitis. 

Etiology. — Metrophlebitis  is  especially  likely  to  occur  when  a  piece 
of  placenta  has  been  left  behind  or  after  the  artificial  detachment  or 
the  low  insertion  of  the  placenta,  particularly  placenta  praevia.  In 
obstetric  operations  in  which  the  hand  is  introduced  into  the  uterus  it 
is  not  rare.  It  is  less  frequently  attributable  to  carcinoma  of  the  cer- 
vix or  deep  lacerations  of  the  perineum. 

Diagnosis. — Uterine  phlebitis  is  often  taken  for  malarial  fevei\  but 
the  chills  come  at  irregular  intervals,  and  later  the  fever  becomes  con- 
tinuous. Swollen  veins  may  be  felt  in  the  pelvis,  and  phlegmasia  alba 
dolens  may  develop  in  the  leg.  There  is  a  tendency  to  uterine  hemor- 
rhage. The  blood  does  not  contain  the  plasmodium,  but  sometimes 
streptococci  are  found.  The  appearance  of  localizations  is  pathogno- 
monic. 

The  differentiation  from  typhoid  fever  may  be  more  difficult,  since 
adynamic  and  ataxic  symptoms  may  be  found  in  both,  and  real 
typhoid  fever  may  attack  a  puerpera,  which,  however,  is  rare.  But 
typhoid  fever  develops  gradually,  while  uterine  phlebitis  begins  sud- 
denly with  a  severe  chill  and  high  fever,  followed  by  almost  normal 
temperature.  Typhoid  fever  is  characterized  by  continuous  fever, 
ochre-colored  stools,  gargouillement  and  tenderness  on  pressure  in 
the  right  iliac  fossa,  and  the  appearance  of  a  few  discrete,  small, 
pink  spots  on  the  abdomen.  Visceral  complications  are  rare.  In 
uterine  phlebitis  there  may  be  gargouillement,  but  no  tenderness  in 
the  right  iliac  fossa.  There  may  be  a  skin  eruption,  but  that  is  spread 
over  larger  surfaces  as  erysipelas,  erythema,  papules,  or  petechiae. 
There  is  no  regular  fever-curve,  and  nearly  all  organs  may  become 
the  seat  of  localizations. 

If  the  infection  follows  the  lymph-vessels,  fever  begins  earlier,  from 
two  to  five  days  after  delivery.  The  chill  is  not  so  pronounced  or 
repeated.     The  fever  is  continuous.     There  is  pain  in  the  lower  part 


716  ABNORMAL   PUERPERY. 

of  the  abdomen,  with  great  tenderness  on  pressure,  the  uterus  is 
large,  and  the  infection  has  a  tendency  to  spread  rapidly  upward  to 
the  peritoneum.  Phlebitis  begins  later,  towards  the  end  of  the  first 
week.  There  is  a  severe  chill,  followed  by  others  with  comparatively 
free  intervals.  There  is  no  pain  and  little  sensitiveness.  The 
uterus  is  better  contracted.  There  generally  come  localizations  with 
infarctions  and  abscesses  in  the  viscera. 

Endocarditis. — The  mflammation  of  the  endocardium  may  be 
found  as  the  only  localization  of  the  infection,  without  pytemia.  Then 
it  begins  in  the  first  days  of  the  puerpery  with  an  intense  chill.  The 
fever  runs  high  with  slight  remissions.  Much  less  frequently  it  has 
an  intermittent  tj-pe.  The  central  nervous  system  is  much  affected. 
The  patient  has  headache,  vertigo,  insomnia  alternating  with  harass- 
mg  dreams.  She  is  hstless,  weak,  delirious.  She  is  in  a  stuporous 
condition  and  talks  in  a  murmuring  way  or  sinks  into  deep  coma. 
More  rarely  she  may  become  maniacal.  The  muscles  of  the  neck 
are  contracted ;  she  grinds  her  teeth,  squints,  enters  mto  convulsions, 
or  becomes  paralyzed.  Hemorrhage  often  takes  place  in  the  retina, 
less  frequently  in  the  choroidea  or  iris.  The  whole  eye  may  be 
destroyed  by  suppuration.  In  the  skin  is  often  found  hemorrhage, 
roseola,  a  scarlatiniform  or  pemphigoid  eruption.  Sometimes  the 
patient  has  diarrhcpa.'  The  disease  lasts  from  ten  to  twenty  days  or 
even  four  weeks. 

When  endocarditis  comes  as  part  of  metrophlebitis  it  appears  late 
in  the  puerpery,  from  ten  to  fifteen  days  after  delivery.  It  is  accom- 
panied by  an  increase  in  fever  and  somnolence.  New  localizations 
may  follow  the  rupture  of  cardiac  abscesses,  but  the  symptoms  of 
these  are  lost  in  those  already  present. 

The  diagnosis  is  based  on  the  cerebral  and  ocular  symptoms. 
Heart  sounds  are  unreliable.  Murmurs  may  be  heard  without  en- 
docarditis and  be  absent  with  it.  Typhoid  fever  is  characterized  by 
its  typical  fever-curve,  the  slight  skin  eruption,  the  oclire-colored 
stools,  and  tenderness  m  the  right  iliac  fossa.  In  urcemia  vomiting  is 
a  predominant  symptom. 

Etiology. — Women  who  have  had  inflammatory  rheumatism  which 
has  left  the  cardiac  valves  rough  and  uneven,  are  predisposed  to 
puerperal  endocarditis. 

Pathology.— The  left  half  of  the  heart  is  more  affected  than  the 
right.  The  valves  are  thickened  and  covered  with  a  deposit  that 
cannot  be  scraped  off.  At  the  same  time  there  is  ulceration  with  a 
loss  of  substance  in  other  places.  In  the  wall  of  the  heart  are  often 
found  miliary  abscesses,  which  may  break  and  empty  their  contents 
—microbes  and  their  chemical  products— into  the  blood-current, 
that  carries  them  through  the  whole  system  and  gives  rise  to  new 


PUERPERAL    IXFECTIOX.  717 

localizations.  The  microscope  reveals  that  the  exudation  and  ulcers 
on  the  valves  and  the  formation  of  abscesses  are  due  to  colonies 
of  cocci. 

A  similar  process  is  more  rarely  found  on  the  tricuspid  valve  or 
in  the  pulmonary  veins. 

The  kidneys  often  contain  miliary  abscesses.  The  dura  and  pia 
mater  may  be  the  seat  of  suppurative  inflammation,  and  in  the  brain 
may  be  abscesses.  Sometimes  there  is  hemorrhage  of  the  meninges 
or  in  the  eye. 

The  prognosis  of  endocarditis  is  bad. 

Disturbances  in  the  Alimentary  Canal. — The  tongue  is  coated  in 
metrophlebitis,  dry,  and  sometimes  the  seat  of  thrush.  There  are 
anorexia,  thirst,  profuse  diarrhoea,  and  sometimes  vomiting.  Rarely 
abscess.es  appear  in  the  parotid,  the  thyroid  gland,  or  the  tonsils,  but 
their  appearance  is  an  unfavorable  prognostic  sign. 

The  liver  is  frequently  implicated.  Then  the  skin  becomes  yellow 
and  often  a  complete  jaundice  is  developed.  The  gland  is  enlarged 
and  tender  on  pressure.  In  connection  with  peritonitis  there  may  be 
perihepatitis  with  formation  of  adhesions,  which  on  pressure  give  that 
crepitation  we  have  spoken  of  above.  Puerperal  jaundice  is  nearly 
always  fatal. 

The  spleen  may  become  inflamed.  The  patient  may  complain  of 
pain  and  tenderness  in  that  region,  the  organ  may  be  felt  enlarged, 
and  the  area  of  dulness  may  be  increased.  If  an  abscess  forms  and 
ruptures  into  the  peritoneal  cavity,  acute  peritonitis  and  death  follow. 
But  mostly  the  symptoms  of  splenitis  are  so  merged  in  others  that 
they  are  not  recognizable. 

Nephritis. — The  inflammation  of  the  kidneys  is  very  common  and 
is  characterized  by  the  presence  of  albumm  and  casts  in  the  urine, 
whereas  the  ordinary  symptoms  of  kidney  inflammation — such  as 
headache,  disturbed  vision,  lumbar  pain,  and  vomiting, — are  lost  in  the 
general  condition.  An  inflammation  of  the  adipose  capsule  may 
perhaps  reveal  itself  by  a  constant  soreness  in  the  lumbar  region. 

Disturbances  in  the  Nervous  System. — Many  nervous  disturb- 
ances, such  as  headache,  neuralgia,  convulsions,  paralysis,  insomnia, 
tetany,  delirium,  insanity,  etc.,  may  occur  during  the  puerperium 
without  being  due  to  puerperal  infection.  They  may  be  caused  by 
anaemia  or  hyperasmia  of  the  brain,  by  pressure  on  a  nerve-trunk,  by 
a  reflex  action,  hysteria,  etc.  But  in  other  cases  the  nervous  phe- 
nomena are  caused  by  metrophlebitis  and  its  metastases,  especially 
endocarditis.  There  may  be  purulent  meningitis  or  encephalitis  or 
thrombosis. 

Insanity  is  in  most  cases  idiopathic  and  may  have  preceded  preg- 
nancy or  developed  during  it.     Sometimes  it  is  due  to  absorption  of 


718  ABNORMAL    PUERPERY. 

toxiiies,  as  when  it  follows  eclampsia  or  iirgeraia.  In  many  cases  there 
is  an  hereditary  predisposition.  PrimiparEe  are  more  prone  to  in- 
sanity than  pluriparae.  But  in  some  cases  the  insanity  is  plainly  due 
to  infection  with  microbes,  which  are  carried  to  the  brain  and  its 
meninges  from  the  genitals.     Then  insanity  is  preceded  by  fever. 

These  patients  are  mostly  melancholic,  with  a  tendency  to  sui- 
cide and  sometimes  to  murder.  They  should,  therefore,  be  watched 
closely. 

ARTHmxis. — Puerperal  infection  sometimes  affects  the  joints,  espe- 
cially the  larger  articulations  of  the  extremities — the  knee,  the  elbow, 
or  the  shoulder.  Among  those  of  the  trmik,  the  symphysis  pubis,  the 
sacro-iliac,  and  the  sternoclavicular  articulations  are  most  frequently 
the  seat  of  the  localization.  Sometimes  many  joints  are  affected 
simultaneously,  but  the  inflammation  disappears  in  most  of  them, 
and  remams  only  in  one  or  two.    • 

The  affected  articulations  become  swollen,  red,  and  painful,  and 
there  is  a  marked  tendency  to  the  formation  of  pyarthrosis,  in  which 
respect  puerperal  arthritis  differs  from  rheumatic  and  gonorrhoeic. 
The  abscess  may  break  through  the  integuments  of  the  joint.  All  the 
tissues,  even  cartilages  and  bones,  may  be  destroyed,  and  if  the 
patient  survives  the  joint  remains  ankylosed. 

Phlegmon  (Cellulitis  of  the  Limbs). — The  subcutaneous  and  the 
intermuscular  connective  tissue  of  the  limbs  may  become  inflamed. 
The  limb  swells,  the  skin  becomes  red  and  hot,  there  is  oedema  or 
fluctuation.  Circumscribed  abscesses  or  wide-spread  destructions  may 
follow.     This  diffuse  phlegmon  is  very  dangerous. 

Skin  Diseases. — A  puerpera  may  be  attacked  by  eruptive  fevers, 
such  as  measles,  scarlet  fever,  or  erysipelas.  Some  eruptions  may  be 
due  to  the  use  of  certain  drugs,  such  as  quinine,  iodide  of  potassium, 
iodoform,  salicylic  acid,  or  copaiba.  Miliaria  may  appear  in  conse- 
quence of  profuse  perspiration. 

In  other  cases,  again,  the  eruption  is  a  sign  of  puerperal  infection. 
Thus,  an  erythema  may  extend  more  or  less  from  the  genitals,  or  large 
purplish  blotches  or  smaller  papules  may  appear  on  any  part  of  the 
body.  Puerperal  eruptions  have  a  darker  color  and  come  and  go.  In 
other  cases  there  are  petechice,  small  dark  spots  due  to  capillary  hem- 
orrhage in  the  skin.  They  do  not  disappear  on  pressure  and  are 
a  bad  prognostic  sign.  Vesicles,  filled  with  serum  like  pemphigus,  or 
bullce,  filled  with  pus,  may  raise  the  epidermis.  Puerperae  are  also 
very  liable  to  bed-sores.  Puerperal  skin  eruptions  are  combined  with 
other  localizations. 

AcuTEST  Septicemia. — This,  the  most  dangerous  of  all  forms  of 
puerperal  infection,  has,  in  consequence  of  antiseptic  and  aseptic 
measures,  become  very  rare,  and  has  disappeared  from  well-conducted 


PUERPERAL   INFECTION.  719 

lying-in  nospitals,  where  in  pre-antiseptic  times  it  frequently  broke  out 
as  so-called  "  epidemics  of  puerperal  fever." 

It  is  sometimes  caused  by  pressure  gangrene  due  to  narrowness 
of  the  pelvis.  In  some  cases  streptococci  have  been  found  in  the 
blood,  but  most  frequently  there  are  no  microbes. 

This  condition  is  ushered  in  by  a  long  and  severe  chill.  Pulse  and 
respiration  are  frequent.  The  temperature  may  be  high,  and  then 
without  those  remissions  we  find  in  metrophlebitis,  but  in  other  cases 
it  may  be  normal  or  even  below  normal.  The  features  are  pinched, 
the  skin  is  pale  or  purplish,  the  tongue  dry  and  brown.  The  patient 
is  somnolent,  delirious,  or  comatose.  The  stools  are  loose,  dark, 
offensive,  and  copious.  The  urine  is  scant  and  loaded  with  albumin. 
Death  follows  in  a  day  or  two. 

Mortality. — With  the  sole  exception  of  tuberculosis,  "  puerperal 
fever  "  is  the  most  fatal  disease  for  women  in  the  child-bearing  period, 
between  15  and  45  years  of  age  ;  and  if  we  take  the  interval  between 
the  25th  and  the  35th  year,  in  which  most  children  are  born,  1  death 
in  every  6  is  due  to  "  puerperal  fever." 

In  Prussia  there  died  during  sixty  years  (1816-1875)  0.8  per  cent. 
of  all  confined  women,  or,  more  exactly,  8322  out  of  every  1,000,000. 
The  governmental  introduction  of  the  use  of  antiseptic  drugs  in  con- 
finement cases  during  the  following  eleven  years  (1876-1886),  reduced 
this  mortality  to  0.58  per  cent.,  or  a  little  less  than  6  per  1000.  In 
Saxony  there  were,  from  1883  to  1896,  2,043,176  births,  with  12,594 
deaths,— 61.63  per  10,000,  or  about  6  per  1000. 

In  lying-in  hospitals  we  might  expect  a  greater  mortality,  be- 
cause many  of  the  worst  cases  are  likely  to  gravitate  to  them.  On 
the  other  hand,  antiseptic  and  aseptic  midwifery  is  carried  out  with 
such  a  thoroughness  there  as  can  hardly  be  obtained  in  private  prac- 
tice.    The  results  are,  therefore,  better  than  might  be  expected. 

In  the  German  lying-in  hospitals  there  were  from  1882  to  1895  in 
41,200  confinements  334 deaths — 0.81  percent.-"  It  is  slightly  higher 
in  New  York  Maternity  Hospital, — 0.87, — but  lower  in  the  Sloane  Ma- 
ternity, where  in  the  first  1000  confinements  they  had  only  6  deaths. 

GoNORRHffiic  Infection. — Gonorrhoeic  infection  forms  really  part  of 
puerperal  infection.  The  gonococcus  may,  like  the  streptococcus,  the 
staphylococcus,  and  others,  lead  to  both  local  and  general  infection, 
to  peritonitis,  arthritis,  endocarditis,  and  death.  Still,  the  affection 
deserves  particular  attention,  because  it  is  caused  by  a  peculiar 
microbe,  the  gonococcus  of  Neisser,  because  it  is  a  common  cause 
of  autoinfection,  and  because,  as  a  rule,  it  is  less  dangerous  than 
infection  with  the  other  cocci. 

The  patient  may  have  the  remnants  of  an  old  gonorrhcea,  which 
did  not  cause  any  symptoms  before  childbirth.    There  may  have  been 


720  ABNORMAL    PUERPERY. 

only  a  few  gonococci  in  her  vagina,  but  a  few  days  after  delivery  they 
abound.  It  seems  that  the  lochial  discharge  constitutes  a  peculiarly 
favorable  soil  for  the  propagation  of  this  microbe,  which  then  may 
ascend  into  the  uterus. 

In  the  beginning  of  the  puerperium  there  may  be  not  any  or  only 
very  slight  symptoms,  such  as  moderate  pain  in  the  uterus  and  a  little 
fever,  and  the  disease  may  stop  short ;  but  two  or  three  weeks  after 
delivery  pyosalpmx,  oophoritis,  and  pelvic  peritonitis  may  develop. 
In  exceptional  cases  this  may  even  happen  early  in  the  puerpery. 

The  diagnosis  is  based  on  the  presence  of  gonococci,  of  venereal 
warts  on  the  genitals  of  the  mother,  and  of  ophthalmia  neonatorum 
in  the  child.  Gonococci  may  be  the  only  infecting  agent,  but  in  other 
cases  they  are  found  together  with  streptococci  and  staphylococci. 

The  treatment  should  chiefly  be  directed  towards  the  vagina,  where 
lysol  douches  (not  corrosive  sublimate)  may  be  used  to  advantage. 
Intra-uterine  injections  and  curetting  are  contraindicated.  The  other 
inflammations  are  treated  with  ice  and  opium. 

§  5.  Treatment. — Puerperal  infection  being  due  to  microbes,  the 
prophylaxis  and  treatment  must  be  directed  against  these  organisms. 

We  know  now  that  puerperal  infection  nearly  always  is  a  wound 
disease,  and  the  methods  by  which  it  is  combated  are  similar  to  those 
used  in  general  surgery.  Obstetricians  were  even  ahead  of  the  sur- 
geons in  recognizing  the  source  of  sepsis  and  inventing  remedies  against 
it ;  but,  strange  enough,  they  did  not  succeed  in  convincing  their  own 
colleagues  until  the  value  of  the  new  methods  was  made  irrefutable  by 
the  results  obtained  by  surgeons. 

The  father  of  antiseptic  midwifery  was  the  Viennese  obstetrician 
Semmelweis.  I  have  looked  in  vain  for  his  name  in  several  large  en- 
cyclopaedias that  mention  every  worthless  potentate  and  every  general 
who  killed  his  fellow-men  on  the  battle-field  ;  and  still  he  was  the  first 
to  understand  the  nature  of  one  of  the  greatest  scourges  of  mankind 
and  to  point  out  a  preventive  against  it.  As  early  as  1847  Semmelweis 
attributed  "  puerperal  fever"  to  infection  from  decaying  cadavers  and 
other  sources,  and  he  introduced  disinfection  of  the  hands  by  means 
of  chloride  of  lime  ;  but  he  preached  to  deaf  ears  and  ended  his  days 
in  a  mad-house.  Half  a  century  had  to  elapse  before  a  statue  was 
erected  in  memory  of  him.  Obstetricians  all  over  the  world  went  on 
carrying  disease  and  death  from  patient  to  patient,  until  Stadfeldt  in 
Copenhagen  and  Bischoff  in  Basel  simultaneously  and  independently 
of  each  other  applied  the  teachings  of  Joseph  Lister  to  obstetrics  by 
introducing  the  use  of  carbolic  acid  (1870). 

The  French  obstetrician  Tarnier  found  by  experimenting  with 
placentas  the  great  antiseptic  value  of  bichloride  of  mercury.  He 
introduced  it  as  a  local  remedy  in  puerperal  fever,  and  submitted  his 


PUERPERAL   INFECTION.  721 

results  to  the  International  Medical  Congress  assembled  in  London  in 
1881,  but  the  great  discovery  passed  unnoticed  until  the  bacteriologist 
Robert  Koch,  in  his  laboratory  in  Berlin,  and  the  surgeon  Schede,  in 
his  hospital  in  Hamburg,  showed  the  immense  value  of  this  drug  in 
preventing  and  combating  microbic  life.  Then  (in  1883)  it  was  intro- 
duced in  many  lying-in  hospitals.  In  America  it  was  first  introduced 
by  the  writer  on  the  first  day  of  October,  1883. 

With  it  came  a  complete  revolution  in  obstetrics,  but  it  has  later 
been  found  that  this  in  reality  was  not  due  to  the  drug,  but  to  the  way 
of  using  it.  We  had  for  years  practised  what  was  then  believed  to  be 
antiseptic  midwifery,  because  carbolic  acid  was  employed,  and  some 
women  were  even  delivered  under  antiseptic  spray.  But  with  the 
year  1883  came  the  strict  disinfection  of  hands,  instruments,  dressing 
material,  etc. 

Several  large  clinics  never  changed  carbolic  acid  for  bichloride  of 
mercury,  and  had  just  as  good  results.  It  was  even  found  that  bi- 
chloride of  mercury  was  a  particularly  dangerous  drug  to  use  on  preg- 
nant, parturient,  and  puerperal  women,  and  its  use  has,  therefore,  in 
the  course  of  time  been  much  limited,  and  it  has  in  part  given  way  to 
innocuous  substances,  like  creolin  or  lysol.  Later,  the  aseptic  method^ 
which  destroys  germs  by  heat,  has  to  some  extent  replaced  its  older 
sister,  the  antiseptic  method,  which  relied  on  the  germicidal  power  of 
certain  chemicals ;  but  even  in  general  surgery  the  older  method  is 
indispensable,  and  this  applies  still  more  to  obstetrics. 

Statistics  are  proverbially  dry  reading,  but  I  cannot  in  any  better 
way  show  the  reader  the  importance  of  the  change  made  in  1883  than 
by  comparing  the  mortality  in  the  New  York  Maternity  Hospital  before 
and  after  that  memorable  date. 

The  maternity  service  was  before  1875  connected  with  Bellevue 
Hospital ;  but  the  mortality  was  so  appalling  that  the  service  was  trans- 
ferred to  Blackwelfs  Island,  and  made  an  annex  of  Charity  Hospital 
(later  called  City  Hospital).  From  that  time  the  statistics  were  as 
follows : 

Year.  Deliveries.  Deaths.  Per  cent. 

1875 570  15  2.63 

1876 ■  ...  536  20  3.73 

1877 480  32  6.67 

1878 255  7  2.75 

1879 254  11  4.33 

1880 149  8  5.37 

1881  ..;... 382  9  2.36 

1882 431  14  3.25 

1883 447  30  >  6.71 

Total 3504  146  4.17 

'  All  (lurini^  the  first  nine  months  of  the  year. 
46 


722  ABNORMAL    PUERPERY. 

During  the  last  six  months  before  the  change  in  treatment  was 
made  there  were  deUvered  237  women,  19  of  whom,  or  8  per  cent., 
died,  and  of  these  17,  or  7.17  per  cent.,  succumbed  to  sepsis.  During 
the  last  month  \he  mortahty  reached  ten  out  of  fifty,  or  20  per  cent., 
and  tliat  from  sepsis,  15.69  per  cent. 

During  the  first  three  months  after  the  change  there  were  dehvered 
102  women  without  a  single  death,  which  at  that  time  seemed  little 
«hort  of  miraculous.  The  following  table  shows  the  mortality  in  Ma- 
ternity Hospital  during  the  first  ten  years  after  the  change  : 

Mortality.  Per  cent.  -c^^™ 

Year.  Deliveries.         rj,^.^.         From  Total  ^J°^ 

^'^^^'^-        Sepsis.        Mortality.  ''^P®^^- 

1884 522  8  4  1.53  0.76 

1885 537  3  0  0.56  0.00 

1886 446  5  1  1.12  0.22 

1887 389  5  1  1.30  0.26 

1888 377  3  0  0.79  0.00 

1889 314  1  0  0.32  0.00 

1890 345  4  1  1.13  0.29 

1891 240  1  0  0.42  0.00 

1892 314  1  0  0.32  0.00 

1893 305  2  0  0.66  0.00 


Total    .     .     .   3789  33  7  0.87  0.18 

By  comparing  this  table  with  the  preceding,  we  find  that  the  mor- 
tality from  all  causes  decreased  from  4.17  to  0.87  per  cent.,  that  is  to 
say,  to  nearly  one-fifth  of  what  it  was  before. 

In  regard  to  morbidity  a  no  less  striking  change  took  place,  but, 
not  having  the  necessary  material  at  command,  the  writer  must  confine 
himself  to  an  example.  During  the  six  months,  from  October  1,  1882, 
to  April  1,  1883,  of  which  period  he  possesses  exact  notes  for  the 
whole  service,  192  women  w6re  delivered,  46  of  whom,  or  nearly  1 
out  of  4,  were  seriously  ill,  and  39,  or  nearly  1  in  5,  suffered  from 
puerperal  inflammation,  which  nowadays  is  attributed  to  infection. 
After  the  change  in  treatment  a  sick  puerpera  became  a  rare  sight. 
By  sick  I  here  mean  ill  enough  to  feel  so  and  demand  therapeutic 
care.  It  would  be  utter  waste  of  time  if  we  should  examine  all  the 
temperatures  registered  before  and  after  the  change.  We  had  often 
considerable  difficulty  in  obtaining  thermometers.  Those  we  obtained 
were  of  the  cheapest  kind.  The  temperatures  were  measured  by 
pupil-nurses.  The  charts  made  from  them  were  of  great  value  to 
the  visiting  obstetrician,  but  they  could  not  possibly  be  used  for  com- 
paring our  institution  with  others,  as  they  do  in  Germany,  where  they 
register  every  patient  as  sick  whose  temperature  at  any  time  rises 
above  100.4°  F. 

In  describing  the  treatment  of  puerperal  infection,  we  must  dis- 


PUERPERAL    INFECTION. 


723 


tinguish  between  hospital  practice  and  private  practice,  propliylaxis 
and  curative  treatment,  which  again  may  be  medical  or  surgical. 

I.  Prevention  of  Puerperal  Infection  in  Hospitals. — Most  of  what 
relates  to  the  precautions  to  be  taken  to  avoid  puerperal  infection  has 
been  discussed  in  speaking  of  lying-in  hospitals  (see  pp.  218-222). 

No  visitors  should  be  admitted  to  the  wards  in  which  women  are 
kept  the  first  nine  days  after  delivery.  Since  the  patients  only  stay 
there  so  short  a  time  there  is  less  necessity  for  seeing  their  friends. 
It  is  a  common  experience  in  hospitals  that  temperatures  generally 
go  up  on  visiting-days,  and  lying-in  women  are  unusually  emotional. 
Besides,  the  visitors  often  come  from  large,  crowded  tenements,  and 
there  is  therefore  a  positive  danger  of  their  bringing  the  germs  of 
measles,  scarlet  fever,  or  diphtheria  to  the  patients  in  the  hospital. 

The  members  of  the  house  staff  should  not  be  permitted  to  enter 
wards  in  which  other  patients  are  kept,  from  whom  infection  might 
be  brought  to  the  parturient  or  newly  confined  women.  Still  less 
should  they  enter  the  dead-house  or  have  anything  to  do  with  patho- 
logical specimens. 

While  in  this  way  we  try  to  keep  all  special  sources  of  infection 
away  from  the  lying-in  hospital,  we  should  do  all  that  is  in  our  power 
to  destroy  germs  of  infection  that  otherwise  might  reach  the  patients. 
The  underlying  principle  is  that  puerperal  infection  is  due  to  microbes 
which  are  found  everywhere, — on  the  patient,  on  the  doctors,  on  the 
nurses,  on  instruments,  on  dressing  material, 
on  clothes,  on  furniture,  and  even  in  the  air  of 
the  room. 

Disinfection  of  Wards. — There  should  be  a 
constant  regular  rotation  in  the  use  of  the  wards. 
As  soon  as  one  set  of  patients  has  been  treated 
in  a  ward,  it  should  be  thoroughly  disinfected. 
This  may  be  done  in  the  following  way.  The 
bedclothes  are  removed  from  the  beds,  sheets 
are  sent  to  the  laundry,  blankets  are  spread 
over  the  ends  of  the  beds,  unless  they  too 
need  washing.  If  mattresses  are  used,  the 
straw  should  be  burned  and  the  ticks  washed. 
In  Maternity  Hospital  we  disinfected  the  wards 
with  sulphur.  All  windows  and  doors  were 
closed,   and  thirty  pounds  of  sulphur  burned 

in  an  iron  pan,  under  which  was  another  pan  with  water.  The  sul- 
phur was  moistened  with  alcohol,  so  as  easily  to  catch  fire.  After  at 
least  six  hours  doors  and  windows  were  opened,  and  if  the  ward  was 
not  needed  immediately  it  was  aired  for  several  days.  But  according 
to  bacteriologists  the  disinfection  by  means  of  formalin  is  much  more 


Fig.  489. 


Formalin  disinfector. 


724  ABNORMAL   PUERPERY. 

effective.  Schering's  formalin  clisinfector  (Fig.  489)  is  arranged  for 
the  vaporization  at  one  time  of  250  pastils,  containing  each  15  grains 
(1  gramme)  of  paraform,  in  which  form  the  formaldehyde  is  harm- 
less. After  the  fumigation  the  floors,  the  walls,  and  the  furniture  were 
scrubbed  with  soap  and  water  and  thereafter  ^dth  bichloride  of  mer- 
cury (1  :  1000).  The  bedsteads  are  made  of  enamelled  iron  and  the 
mattresses  of  woven  wire.  All  bedclothes  and  linen  used  by  sick 
puerperse  were  immersed  in  the  same  solution  of  corrosive  sublimate 
for  an  hour,  and  then  washed  before  being  sent  to  the  common 
laundrj^  Patients  and  nurses  wore  only  clothes  made  of  washable 
goods.  The  clothes  of  the  doctors  who  had  been  engaged  in  the 
isolation  department  were  hung  up  in  a  small  room  and  fumigated 
with  sulphur. 

Disinfection  of  Patient. — When  a  patient  is  taken  m  labor,  she  is 
given  a  general  warm  bath  and  scrubbed  with  soap,  and  dressed  in 
clean  clothes.  Next,  she  is  placed  on  the  delivery-bed  on  a  rubber 
blanket  that  has  been  disinfected  with  corrosive  sublimate  or  sterilized 
by  heat.  The  abdomen,  buttocks,  and  thighs  are  washed  with  corro- 
sive sublimate  (1  :  2000),  taking  particular  care  to  clean  every  furrow 
at  the  genitals  and  umbilicus. 

Disinfection  of  Doctors  and  Nurses. — The  obstetrician  takes  off 
his  coat,  vest,  necktie,  collar,  and  cuffs,  rolls  up  the  sleeves  of  his 
shirt  and  undershirt  to  the  middle  of  the  arm  above  the  elbow,  and 
ties  a  rubber  apron  around  his  body  from  the  armpits  to  the  ankles. 
He  disinfects  hands  and  arms  with  potassa  soap,  hot  water,  and  cor- 
rosive sublimate  as  described  (p.  218),  and  finally  he  dons  a  sterilized 
gown  and  cap.  He  is  now  ready  for  work,  but  as  it  is  next  to  impos- 
sible in  obstetric  practice  wholly  to  avoid  handling  anything  from 
which  new  germs  might  be  carried  to  the  patient,  a  basin  with  lysol 
emulsion  (1  :  100)  is  kept  at  the  bedside,  in  which  he  immerses  his 
hand  before  touching  the  patient. 

The  nurses  disinfect  themselves  in  the  same  way. 

The  use  of  bichloride  of  mercury  for  disinfection  may  be  supple- 
mented by  other  disinfectants,  such  as  lysol,  chlorine,  and  alcohol. 
Chlorine  is  developed  by  mixing  a  teaspoonful  of  chlorinated  lime 
with  as  much  carbonate  of  potassium  and  a  little  water  so  as  to  form 
a  paste,  with  which  hands  and  arms  are  smeared,  and  then  rinsed 
with  water.  After  that  they  may  be  immersed  in  lysol  (1  :  100), 
which  renders  its  smoothness  to  the  skin  roughened  by  corrosive 
sublimate.  And,  finally,  they  may  be  immersed  in  alcohol  or  rubbed 
with  pledgets  of  absorbent  cotton  or  a  flannel  rag  soaked  in  the 
same. 

Disinfection  of  Materials. — All  materials,  such  as  gauze,  absorbent 
cotton,  etc.,  that  come  in  contact  with  the  genitals,  should  be  steril- 


PUERPERAL   INFECTION.  725 

ized  by  moving  steam  mider  high  pressure.  Xo  sponges  are  used. 
They  have  been  replaced  by  absorbent  cotton  and  gauze. 

Disinfection  of  Instruments. — All  instruments  are  sterilized  by  boiling 
them  for  five  minutes  in  a  solution  of  washing-soda  (a  tablespoonful 
for  each  quart  of  water),  and  after  being  used  they  are  carefully 
cleaned  with  soap  and  water  and  kept  in  a  suitaJDle  closet.  All  in- 
struments composed  of  several  parts  should  be  taken  apart.  All 
sutures  and  ligatures  should  be  sterile.  Silkworm  gut  may  be  boiled 
in  water  and  kept  in  alcohol.  Silk  may  be  disinfected  by  exposing  it 
for  an  hour  to  the  steam  of  the  sterilizer.  Catgut  may  be  sterilized 
by  treating  it  with  formalin,  cumol,  or  dry  heat.^ 

Antiseptic  Conduct  of  Labor. — Vaginal  examinations  are  restricted 
as  much  as  possible,  and  immediately  before  each  the  accoucheur  dis- 
infects his  hands.  The  vulva  is  spread  wide  open.  Under  ordinary 
circumstances  the  examining  finger  does  not  enter  beyond  the  exter- 
nal OS,  so  as  to  avoid  carrying  any  germs  from  the  vulva,  the  vagina, 
or  the  cervix  to  the  uterine  cavity.  No  lubricants  are  used  for  hands 
or  instruments,  the  adherent  lysol  or  creolin  being  amply  sufficient. 
The  only  exception  from  this  rule  is  when  it  becomes  necessary  to 
introduce  the  whole  hand, — for  instance,  in  podalic  version  or  artificial 
removal  of  the  placenta.  Then  the  dorsal  surface  of  the  hand  should 
be  made  slippery  with  sterilized  oil,  alboline,  lubrichondrin,  or  white 
vaseline  in  tubes,  or  mollin  impregnated  with  five  per  cent,  carbolic  acid. 

When  the  head  begins  to  open  the  rima  pudendi,  the  genitals  are 
covered  with  a  sterile  gauze  pad,  which  serves  the  double  purpose  of 
keeping  out  microbes  and  mechanically  facilitating  all  manipulations  by 
obviating  too  great  slipperiness. 

The  placenta  is  removed  by  expression  (see  p.  196),  If  on  inspec- 
tion any  part  of  it  is  missing,  the  well-disinfected  hand  should  be  intro- 
duced and  the  remnant  scraped  off  with  the  nails,  while  the  uterus  is 
steadied  from  without  with  the  other  hand.  If  a  large  piece  of  the 
membranes  is  retained,  it  may  be  removed  in  the  same  way ;  or,  if  it 
is  within  reach  from  the  vulva,  a  silk  thread  may  be  tied  to  it,  by  pull- 
ing on  which  the  next  day  the  retained  portion  comes  out. 

A  prophylactic  intra-uterine  injection  is  given  when  the  uterus  has 
been  entered  (p.  580). 

Next,  the  patient  is  cleaned  and  the  abdominal  binder  and  perineal 
occlusion-dressing  put  on  as  described  under  The  Conduct  of  Normal 
Labor  (p.  200),  only  instead  of  dipping  the  pad  in  antiseptic  fluid  it 
is  sterilized  by  steam. 

Ergot. — Since  good  uterine  contraction  is  a  preventive  of  infection, 
ergot  forms  part  of  the  preventive  antisepsis.  A  drachm  of  the  fluid 
extract  is  given  three  times  a  day  during  the  first  three  days. 

^  For  details  see  Garrigues,  Diseases  of  Women,  third  ed.,  pp.  213-215. 


726  ABNORMAL   PUERPERY. 

Perineorrhaphy. — All  lacerations  of  the  perineum  should  be  im- 
mediately repaired,  as  thereby  we  close  the  door  against  the  entrance 
of  microbes  (see  p.  543), 

Catheterization. — If  the  patient  cannot  urinate,  which  is  especially 
common  after  perineorrhaphy,  the  urine  must  be  drawn  with  a  cathe- 
ter. Before  doing  so  the  vulva  should  be  spread  open  and  the  sur- 
roundings of  the  meatus  washed  with  creolin  or  lysol  emulsion.  The 
catheter  is,  of  course,  disinfected.  For  common  use  glass  catheters 
are  the  best,  and  are  disinfected  by  boiling  in  soda  solution ;  but  if 
there  is  any  resistance  to  overcome,  as  when  the  head  presses  on  the 
urethra,  the  glass  might  break.  Then  some  other  kind  is  needed  (see 
pp.  434,  607). 

Syringes. — Syringes  have  probably  done  greater  harm  than  any 
other  instrument.  Being  used  on  one  patient  after  the  other  without 
disinfection  they  were  probably  the  greatest  carrier  of  infection.  In 
hospitals  glass  nozzles  should  be  used,  which  are  easily  disinfected  and 
so  cheap  that  one  does  not  hesitate  to  destroy  them  when  they  have 
been  used  in  an  infected  patient. 

II.  Prevention  of  Puerperal  Infection  in  Private  Practice. — All 
over  the  civilized  world  lying-in  hospitals  now  use  similar  antiseptic 
and  aseptic  precautions,  and  the  result  has  been  that  their  mortality 
ranges  as  low  as  from  0.8  down  to  0.3  per  cent.  In  private  practice 
some  little  improvement  has  been  statistically  demonstrated  to  have 
taken  place  in  some  localities  ;  in  others  there  is  none.  This  unsatis- 
factory showing  is  due  to  the  fact  that  midwives  and  physicians  have 
only  reluctantly  followed  the  movement  that  has  revolutionized  modern 
obstetrics,  or  have  kept  entirely  aloof  from  it.  Nearly  one-half  the 
confinements  in  the  city  of  New  York  are  in  the  hands  of  midwives, 
who  come  from  all  parts  of  the  world  or  have  taken  a  short  course  in 
one  of  the  private  schools  of  midwifery  in  the  city.  They  are  under  no 
control.  Since  even  in  countries  where  they  study  two  years,  where 
they  are  taught  by  university  professors,  where  they  must  pass  an 
examination  before  they  can  practise  midwifery,  and  where  they  are 
under  constant  control  of  physicians  appointed  by  the  government — 
since  even  there  constant  complaints  are  made  about  their  inefficiency, 
and  especially  the  unsatisfactory  way  in  which  they  use  antiseptics,  Ave 
may  take  it  for  granted  that  in  America  they  practically  do  not  use  them 
at  all.  Unfortunately,  it  is  not  much  better  among  physicians.  Out- 
side of  the  small  number  who  have  received  their  training  in  lying-in 
hospitals,  it  is  to  be  feared  that  they  either  do  not  use  any  preventives 
at  all  or  use  them  in  such  a  happy-go-lucky  way  that  little  benefit  is 
derived  from  them.  The  result  is  that,  while  formerly  lying-in  hos- 
pitals were  responsible  for  much  suffering,  many  deaths,  and  whole 
epidemics,  they  have  now  become  the  safest  places  in  the  world  to  be 


PUERPERAL   INFECTION.  727 

confined  in.     In  private  practice  the  mortality  is  two  or  th^ee  times  as 
large  as  in  well-conducted  hospitals. 

On  October  27,  1892,  the  Obstetric  Section  of  the  New  York 
Academy  of  Medicine,  on  a  motion  by  the  writer,  unanimously  passed 
the  following  resolution : 

Whereas,  Experience,  both  in  this  country  and  abroad,  shows  that  by  strict 
antiseptic  measures  the  total  mortality  in  lying-in  hospitals  may  be  reduced  to  a 
few  per  thousand  ; 

Whereas,  Deaths  due  to  childbirth  or  to  abortion  yet  are  common  in  private 
practice  ; 

Resolved,  That,  in  the  opinion  of  the  Obstetric  Section  of  the  New  York 
Academy  of  Medicine,  it  is  the  duty  of  every  physician  practising  midwifery  to 
surround  such  cases  in  private  practice  with  the  same  safeguards  that  are  being 
used  in  hospitals. 

Since  this  resolution  was  formulated  considerable  changes  have 
been  made  in  hospital  practice,  the  rules  of  aseptic  midwifery  having 
replaced  those  of  antiseptic  midwifery.  In  private  practice  the  author 
thinks  we  should  chiefly  be  satisfied  with  antiseptic  measures  (see 
pp.  185,  594).  The  rules  for  the  antiseptic  conduct  of  labor  in  pri- 
vate practice  have  been  given  above  in  speaking  of  the  management 
of  normal  labor  (pp.  188-190).  It  has  also  been  shown  how  the  ex- 
pense may  be  reduced  to  a  minimum  where  the  patient's  means  do 
not  allow  more  elaborate  measures  (p.  202).  The  disinfection  of  the 
vagina  previous  to  operations  is  described  on  page  567. 

For  suture  material  it  is  convenient  to  use  that  prepared  by  reliable 
manufacturers  by  boiling  in  alcohol,  at  a  high  temperature,  in  hermeti- 
cally closed  glass  tubes,  which  is  easily  carried  in  the  satchel. 

If  only  physicians  and  nurses  would  understand  that  to  make  a 
vaginal  examination  during  labor  without  disinfecting  the  hands  is  to 
.expose  the  patient  to  the  danger  of  painful,  perhaps  incurable,  dis- 
ease or  death !  If  no  measurements  have  been  taken  of  pelvis  and 
fcEtus,  a  serious  mechanical  disproportion  may  appear  unexpectedly 
during  the  course  of  labor.  The  most  severe  complications,  such  as 
hemorrhage  or  convulsions,  may  call  for  immediate  interference.  The 
most  dangerous  operations,  such  as  symphyseotomy,  C;3esarean  sec- 
tion, or  Porro's  operation,  may  become  necessary.  Even  the  choice 
of  the  operation  often  depends  upon  the  aseptic  or  septic  condi- 
tion of  the  patient,  that  being  the  predominant  factor  in  the  result. 
Every  labor  should,  therefore,  from  the  very  beginning  and  through- 
out its  course  be  conducted  according  to  the  rules  of  antiseptic  mid- 
wifery. If  then  complications  arise  for  which  the  help  of  the  expert 
is  sought,  he  finds  a  clean  field,  where  his  knowledge  and  skill  may 
be  displayed  to  his  own  honor  and  the  welfare  of  the  patient.  Other- 
wise, all  his  learning  and  talent  may  be  of  no  avail. 


728  ABNORMAL   PUERPERY. 

III.  Curative  Treatment  of  Puerperal  Infection. — While  we  have 
made  such,  astounding  progress  within  the  last  twenty  years  in  the 
prevention  of  puerperal  infection,  little  has  been  accomplished  in  the 
way  of  a  cure  when  once  the  disease  has  started.  We  shall  in  the 
exposition  of  the  therapeutic  and  surgical  means  at  our  command  in 
combating  it  follow  the  same  anatomical  divisions  as  heretofore ;  but, 
in  order  to  avoid  endless  repetitions,  a  procedure  will  be  mentioned 
only  in  speaking  of  that  organ  in  the  affection  of  which  it  is  chiefly 
used,  but  it  should  be  understood  that  similar  conditions  in  other 
organs  are  treated  in  the  same  way.  Thus  the  temperature-reduc- 
ing remedies  are  described  under  peritonitis,  but  a  high  temperature 
due  to  metrophlebitis  or  other  inflammations  demands  the  same  treat- 
ment. 

Some  general  rules  may  help  the  practitioner  in  the  choice  of  the 
remedial  resources  in  the  particular  cases. 

1.  The  first  indication  is  to  remove  those  microbes  which  are  in 
the  genital  canal,  but  have  not  yet  entered  the  tissues.  This  is  done 
by  ablutions  and  injections  with  antiseptic  fluids. 

2.  The  second  indication  is  to  seal  the  entrances  into  the  tissue,. 
which  is  done  by  means  of  cauterization. 

3.  The  third  indication  is  to  clean  the  intestinal  canal  by  enemas,, 
aperient  medicines,  and  internal  antiseptics. 

4.  The  fourth  indication  is  to  sustain  the  patient's  strength  in 
order  to  give  her  a  chance  of  throwing  out  the  organisms  and  the 
poison  that  already  have  invaded  her  tissues  and  circulate  with  her 
blood.  For  this  purpose  stimulants  are  used  freely ;  as  much  sub- 
stantial food  should  be  given  as  the  patient  can  digest;  and  tonic 
drugs  should  be  administered. 

5.  The  fifth  indication  is  to  combat  pain,  which  exhausts  vitality. 
This  is  done  with  narcotics  and  the  local  application  of  ice. 

6.  The  sixth  indication  is  to  reduce  the  patient's  temperature 
when  it  becomes  dangerously  high,  which  indication  is  met  with 
refreshing  ablutions,  ice-bags,  ice-water  coils,  or  cooling  baths. 

Sapr^mia. — Sometimes  the  lochia  become  fetid,  pulse  and  respi- 
ration are  accelerated,  the  temperature  may  rise  to  102°  F.,  but  there 
is  no  pain,  no  tenderness,  no  swelling,  no  ulceration,  and  no  somno- 
lence. This  condition  is  probably  due  to  a  mild  degree  of  infection 
with  saprophytes.  Often  a  blood-clot  hidden  in  the  deep  posterior 
vault  of  the  vagina  or  in  the  interior  of  the  uterus  or  retention  of  the 
lochia  in  the  uterine  cavity,  so-called  lochiometm,  is  the  cause.  Health 
is  generally  soon  restored  by  raising  and  slightly  squeezing  the  uterus, 
using  vaginal  douches  with  lysol  or  ereolin  every  three  hours,  and 
giving  a  saline  aperient  and  a  capsule  with  five  grains  of  quinine  three 
or  four  times  a  day. 


PUERPERAL   INFECTION.  729 

^Ed(eitis  and  Colpitis. — Simple  catarrhal  inflammation  of  the  vulva 
and  the  vagina  is  treated  with  the  just-named  vaginal  injections. 
Simple  tears  and  abrasions  heal  under  the  occlusion-dressing.  Excep- 
tionally they  may  be  dusted  with  iodoform,  aristol,  dermatol,  stearate 
of  zinc,  or  covered  with  this  ointment : 

R    lodoformi,  ^i  (4  grammes)  ; 

Balsami  peruviani,  ^^ii  (8  grammes)  ; 
Vaselini,  q.  s.  ad  ^ii  (60  grammes). — M. 

If  the  wounds  become  diphtheritic,  the  author  touches  them  with 
a  strong  solution  of  chloride  of  zinc  : 

Be    Zinci  chloridi, 

Aqua3  destillatae,  aa  ji  (4  grammes), 

which  is  applied  by  means  of  absorbent  cotton  wound  around  some 
suitable  stick,  such  as  a  toothpick,  a  match,  or  a  lead-pencil.  The 
caustic  should  be  applied  all  over  the  infiltrated  surface  and  held  in 
contact  for  a  minute.  Besides,  the  vagina  is  syringed  with  creolin  or 
lysol  emulsion.  If  the  perineum  has  been  stitched,  the  sutures 
should  be  cut,  as  the  surface  is  doomed  to  infection  and  must  be  cau- 
terized. Tears  in  the  deeper  part  of  the  vagina  are  made  accessible 
by  means  of  a  bivalve  speculum.  The  cauterization  being  very  pain- 
ful, the  parts  should  be  anaesthetized  with  a  10-per-cent.  solution  of 
cocaine,  or  general  anaesthesia  should  be  induced. 

The  chloride  of  zinc  has  the  effect  of  making  the  ulcers  milk- 
white.  Later  a  grayish  slough  is  produced,  which  is  much  like  a 
diphtheritic  patch,  but  may  be  distinguished  from  it  by  its  plain 
contour,  while  the  diphtheritic  infiltration  spreads  with  a  scalloped 
outline. 

The  aim  of  this  cauterization  is  a  double  one,  namely,  to  kill  the 
microbes  on  the  surface  of  the  wound  and  to  seal  the  veins  and 
lymphatics  starting  from  it.  The  author  has  found  chloride  of  zinc 
much  more  effective  for  this  purpose  than  tincture  of  iodine,  iodo- 
form, liquor  ferri  chloridi,  or  Monsell's  solution. 

The  bowels  should  be  moved.  Half  an  ounce  of  brandy  or  whis- 
key should  be  given  every  two  hours,  mixed  with  equal  parts  of  milk 
or  water.  For  a  change  eggnog  may  be  given  two  or  three  times  a 
day.  If  strong  liquor  is  not  well  borne,  champagne,  madeira,  port, 
sherry,  malaga,  marsala,  tokay,  or  other  strong  wines  may  be  sub- 
stituted ;  but,  as  a  rule,  large  amounts  of  alcoliol  can  be  taken  with- 
out producing  intoxication.  If  there  is  a  patient  suffering  from  diph- 
theria in  the  house,  or  if  cultures  made  from  the  ulcers  show  the 
presence  of  the  Klebs-Loffler  bacillus  of  diphtheria,  the  correspond- 
ing antitoxin  should  be  injected  subcutaneously. 


730  ABNORMAL    PUERPERY. 

If  there  is  gangrene  of  the  vulva  or  the  vagina,  the  stimulating 
treatment  should  be  pushed  still  more.  As  soon  as  a  line  of  de- 
marcation is  established,  the  dead  tissue  should  be  cut  away  with 
knife  or  scissors,  and  granulation  promoted  by  the  application  of 
camphor  emulsion  (see  under  Bed-sores). 

Endometritis  and  Metritis. — When  the  uterus  itself  is  the  seat  of 
the  inflammation,  the  obstetrician  must  first  of  all  know  if  it  is  empty 
or  part  of  the  secundines  are  retained  and  are  undergoing  decompo- 
sition. If  there  is  the  slightest  doubt  in  this  respect,  the  first  indica- 
tion is  to  examine  the  interior  of  the  uterus  and  if  any  part  of  the 
after-birth  is  retained  to  remove  it.  For  this  purpose  the  patient  is 
placed  across  the  bed  or  on  a  table  in  the  dorsal  position,  with  the 
knees  bent,  separated,  and  elevated.  She  is  anaesthetized.  The  opera- 
tor introduces  the  disinfected  and  lubricated  hand  into  the  vagina  and 
one  or  two  fingers  into  the  uterus.  If  necessary,  the  whole  hand 
may  be  inserted.  In  cases  of  puerperal  infection,  the  cervix  often 
remains  open  and  dilatable  for  many  days.  If  necessary,  it  is  dilated 
by  means  of  dilators.  As  a  rule,  it  is  best  to  introduce  the  left  hand, 
that  being  the  smaller  one.  The  other  is  placed  on  the  fundus, 
steadies  it,  and  presses  it  down  against  the  internal  hand.  The 
accoucheur  should  go  systematically  over  the  whole  interior  surface, 
and  pay  special  attention  to  the  cornua,  which  are  most  difficult  to 
reach,  and  where  a  piece  of  placenta  is  most  frequently  retained.  If 
possible,  it  is  an  advantage  to  enter  on  one  side  of  the  retained  part 
and  loosen  it  all  in  one  piece,  by  inserting  the  finger-nails  with  a  saw- 
ing movement  between  it  and  the  uterine  wall.  But  if  this  cannot  be 
done,  one  must  remove  it  piecemeal.  It  is  not  necessary  to  with- 
draw the  hand.  By  pressing  the  fingers  against  the  palm  of  the  hand, 
the  detached  portion  is  made  to  descend  along  the  inside  of  the  fore- 
arm to  the  OS,  from  which  all  is  finally  removed  in  withdrawing  the 
hand. 

To  scrape  the  uterus  with  the  large  dull  wire  curette  in  order  to 
remove  retained  parts  of  the  after-birth  is  not  advisable.  Immedi- 
ately after  delivery  the  removal  is  done  much  better  with  the  hand, 
and  when  the  uterus  is  infected,  the  scraping  does  more  harm  than 
good.  The  writer  does  not  remember  ever  to  have  seen  a  patient 
recover,  w^hen  the  curette  was  used  after  sepsis  had  set  in  after 
childbirth.  To  use  curettage  to  scrape  off  the  endometrium  is  still 
more  reprehensible.  By  the  use  of  the  curette  we  break  down  the 
wall  that  nature  has  built  to  keep  out  the  infection  from  the  deeper 
parts,  and  we  carry  microbes  right  into  the  fine  branches  of  veins 
and  lymphatics. 

After  the  uterus  has  been  cleared,  it  should  be  washed  out  with 
a  copious  injection — 2  or  3  quarts — of  a  1  per  cent,  solution  of  lysol 


PUERPERAL    INFECTION.  731 

or  creolin.  But  this  should  not  be  repeated.  Bacteriological  exam- 
inations have  shown  that  shortly  after  an  injection  there  are  as  many 
streptococci  as  before  in  the  uterine  cavity.  They  cannot  be  kept  away 
by  douching,  and  their  virulence  is  not  diminished  by  it.  The  injec- 
tion often  does  positive  harm.  I  have  seen  cases  in  which  each  intra- 
uterine injection  caused  a  rise  in  temperature,  and  the  patients  got  well 
when  they  were  discontinued.  Especially  if  they  are  given  with  a 
metal  or  glass  tube,  small  wounds  are  torn  open  and  new  ones  inflicted 
in  the  genital  tract.  But  one  copious  injection  is  useful  in  removing 
debris  and  thoroughly  cleaning  the  cavity. 

After  that  the  uterus  may  be  packed  with  iodoform  gauze.  If  there 
is  no  bleeding  the  author  prefers  the  introduction  once  a  day  of  an 
intra-uterine  suppository  with  iodoform. 

B   lodoformi,  gv  (20  grammes)  ; 
Amyli,  ^:^ss  (2  grammes)  ; 
Glycerini,  fl^ss  (2  grammes)  ; 
Acacias,  ^i  (4  grammes). — M. 
Ft.  suppositoria  No.  iii.  of  the  size  and  shape  of  the  little  finger. 

The  suppository  is  introduced  through  a  bivalve  speculum  by 
means  of  a  forceps  with  the  curvature  of  the  uterine  sound  (Fig.  41 6, 
p.  574).  If  the  patient's  condition  is  satisfactory,  the  intra-uterine 
treatment  is  not  repeated.  But  vaginal  douches  should  be  given  every 
three  hours,  which  prevent  stagnation  of  infected  fluid  in  the  vagina 
and  incite  the  uterus  to  contraction.  Involution  is  also  promoted  by 
the  administration  of  ergot  and  the  application  of  the  faradic  current. 

The  inflammation  and  especially  the  pain  are  combated  by  cold. 
For  this  purpose  a  large  ice-bag  is  placed  on  the  hypogastric  region, 
or  the  lower  part  of  the  abdomen  is  covered  with  a  rubber  coil  with  a 
permanent  current  of  ice-water.  In  order  to  avoid  local  freezing, 
about  four  layers  of  muslin  should  be  put  between  the  ice-bag  and  the 
skin. 

If  the  patient  has  diarrhoea,  or  the  inflammation  has  the  diphthe- 
ritic character,  or  otherwise  there  are  signs  of  low  vitality,  cold  is  not 
well  borne.  Then  a  linseed-meal  poultice  or  a  double  piece  of  flannel 
wrung  out  of  hot  water  should  take  the  place  of  the  ice-bag,  and  be 
kept  well  covered  with  water-proof  and  woollen  material.  It  is  re- 
newed as  often  as  it  cools  off, — about  every  two  hours. 

When  the  inflammation  subsides  the  ice-bag  should  be  replaced 
by  a  Priessnitz  compress,  made  of  a  towel  wrung  out  of  cold  water 
and  covered  with  water-proof.  It  becomes  warm  in  a  short  time  and 
furthers  reabsorption  of  inflammatory  products. 

The  internal  treatment  consists  in  quinine,  moderate  doses  of  alco- 
hol, and  a  little  opium. 


732  ABNORMAL   PUERPERY. 

If  the  cervix  is  the  seat  of  diphtheritic  patches,  the  treatment  should 
be  much  more  energetic.  Then  the  whole  cervical  membrane  is 
cauterized  with  the  above-mentioned  chloride  of  zinc  solution,  and 
the  cauterization,  if  necessary,  is  repeated  once  in  twenty-four  hours. 
The  uterus  is  washed  out  once  a  day  with  antiseptic  fluid,  and  an 
iodoform  pencil  is  left  in  it.  This  treatment  is  continued  till  all  sloughs 
are  thrown  off.  Quinine  and  alcohol  should  be  prescribed  vrith  shorter 
intervals.  At  least  twelve  ounces  of  whiskey  or  brandy  should  be 
given  in  the  twenty-four  hours. 

If  there  is  any  sign  of  weakening  of  the  heart,  digitalis  should 
be  given, — preferably  the  officinal  infusion  in  half-ounce  doses  (15 
grammes)  four  times  a  day ;  but  if  the  patient  cannot  swallow  or 
vomits,  the  tincture  may  be  injected  subcutaneously  (n^^v-x, — from 
30  to  60  centigrammes, — repeated  according  to  circumstances).  Tinc- 
tura  strophanthi  (n^v  or  vi — 30  or  35  centigTammes)  is  also  useful. 
In  more  acute  cases  nitroglycerin  (gr.  jI-q  to  -^ — from  -^  to  21  milli- 
grammes) and  strychnine  (gr.  2V  to  y^o — fro™  3  to  6  milligrammes) 
are  injected  hypodermically. 

In  dissecting  metritis  the  purulent  discharge  from  the  uterus 
should  be  combated  and  the  expulsion  of  the  detached  portion 
favored  by  daily  intra-uterine  douches  with  creolin  or  lysol  {\  of  1 
per  cent.),  or  the  saturated  solution  of  boric  acid  should  be  used. 
The  fluid  should  always  be  warm,  as  cold  injections  into  the  uterus 
sometimes  cause  collapse. 

Putrescence  of  the  iderus  has  disappeared  since  the  introduction  of 
aseptic  and  antiseptic  midwifery.  If  the  writer  met  with  a  case,  he 
would  treat  it  with  intra-uterine  injections,  iodoform  suppositories, 
quinine,  strychnine,  digitalis,  strophanthus,  the  largest  doses  of  alcohol 
that  could  be  borne,  and  nitrogenous  food. 

Since  the  uterus  is  the  most  common  starting-point  of  general  in- 
fection, and  since  it  evidently  is  in  the  highest  degree  desirable  to 
arrest  the  infection  there,  I  shall  here  mention  several  other  resources 
at  our  command. 

Unguentum  Crede  is  an  ointment  containing  silver  in  a  soluble  form. 
From  30  to  45  grains  (2-3  grammes)  of  it  are  rubbed  once  a  day  on 
places  where  the  skin  is  particularly  soft  and  free  from  hair,  as,  for 
instance,  the  inside  of  the  arms  or  the  thighs,  the  chest,  or  the  abdo- 
men. The  active  part  of  it  is  called  collar golum,  argentum  solubile 
Crede,  or  argentum  coUoidale.  It  may  also  be  used  hypodermically, 
intravenously,  by  the  mouth  in  capsule  or  solution,  or  it  may  be 
apphed  to  wounds  or  placed  in  pill  form  in  the  uterine  cavity  or,  at 
the  end  of  laparotomy,  in  the  peritoneal  cavity.  It  enters  the  lym- 
phatics and  circulates  dissolved  in  the  blood.  The  inunction  method 
has  been  in  use  for  some  years.     The  intravenous  method  has  been 


PUERPERAL   INFECTION.  733 

recommended  quite  recently  (1901).  Any  convenient  and  prominent 
vein  may  be  employed.  The  most  suitable  is  the  left  cephalic.  The 
patient  being  in  the  recumbent  position,  the  arm  is  allowed  to  hang 
down  for  a  minute,  and  a  bandage  or  ligature  is  firmly  tied  around  it, 
after  which  the  arm  is  permitted  to  hang  down  for  one  or  two  minutes 
longer.  The  skin  is  then  disinfected  and  a  hypodermic  needle  pushed 
into  the  vein.  If  the  point  is  in  the  lumen  of  the  vein,  blood  will 
flow.  If  it  does  not,  the  needle  must  be  introduced  again  till  it  does. 
The  syringe  is  then  attached,  the  ligature  around  the  arm  is  removed, 
and  the  solution  is  injected  slowly  and  with  frequent  pauses.  It  is 
desirable  to  inject  not  less  than  5  centigrammes  (|  grain)  of  collar- 
golum  in  an  adult.  The  collargolum  is  administered  in  a  1  per  cent, 
or  a  J  of  1  per  cent,  solution.  A  common  hypodermic  syringe  would 
have  to  be  refilled  five  times,  which  is  inconvenient,  and  might  lead 
to  the  displacement  of  the  needle.  It  is,  therefore,  better  to  use  a 
syringe  holding  not  less  than  10  grammes  (siiss). 

If  the  vein  cannot  be  made  turgid,  it  must  be  laid  free  through  a 
small  incision  in  the  skin.  A  fine  probe-pointed  silver  canula,  such  as 
is  found  in  my  transfusion-apparatus  (Fig,  421,  p.  582),  is  introduced 
through  a  nick  made  with  scissors  in  the  vein.  In  order  to  prevent 
the  tube  from  slipping  out,  a  catgut  ligature  may  be  laid  under  the 
vein  and  tied  behind  the  bulb  of  the  tube.  A  syringe  holding  about 
20  grammes  (sv)  is  attached  to  the  canula,  and  aspiration  made,  so 
as  to  suck  out  the  air  from  the  canula.  Next,  10  to  20  grammes  (^iiss 
to  3v)  of  a  4^  of  1  per  cent,  solution  of  collargolum  is  slowly  pressed 
into  the  vein.  The  wound  is  closed  Avith  sutures  or  simply  dressed 
as  after  phlebotomy.  If  the  needle  is  thrust  through  the  skin,  the 
opening  is  covered  with  a  piece  of  adhesive  plaster.  The  usual  amount 
injected  is  from  5  to  10  grammes  (IJ  to  2|  drachms)  of  the  stronger 
or  10  to  20  grammes  (2J  to  5  drachms)  of  the  weaker  solution.  The 
solution  is  made  by  simply  shaking  the  collargolum  with  distilled 
water.  It  is  decomposed  by  being  rubbed  in  a  mortar.  The  solu- 
tion should  stand  quietly  for  a  few  minutes  before  using  it,  so  that 
any  undissolved  or  reprecipitated  silver  may  settle  to  the  bottom  of 
the  vessel,  and  the  injection  fluid  is  taken  from  the  upper  half  of 
its  contents. 

In  well-closed  vessels  the  solution  can  be  kept  for  many  months. 
To  test  it  a  little  is  poured  into  distilled  water.  If  the  water  re- 
mains clear  and  becomes  brownish  or  olive-green  in  color,  the  fluid 
is  in  good  condition  ;  but  if  it  becomes  cloudy  and  silver-gray,  the 
solution  is  unfit  for  use. 

Not  unfrequently  a  chilly  feeling  or  a  distinct  chill  with  fever 
occurs  from  two  to  four  hours  after  the  injection,  but  it  soon  passes 
off  and  leaves  not  the  slightest  ill  effect.      The  effect  of  the  intra- 


734  ABNORMAL   PUERPERY. 

venous  injection  on  the  disease  is  much  greater  than  that  of  inunc- 
tion with  the  ointment.  It  may  have  to  be  repeated  once  or  oftener 
on  the  following  and  subsequent  days.^^  My  limited  personal  experi- 
ence with  collargolum,  both  as  ointment  and  applied  by  intravenous 
injection,  has  not  given  me  satisfaction.  It  reduced  temperature  and 
there  was  no  unpleasant  effect,  but  the  patients  died. 

Marmorelcs  antistreptococciG  serum  is  a  fluid  obtained  in  a  way 
similar  to  that  by  which  antidiphtheritic  serum  is  produced,  but  it  has 
by  far  not  proved  so  useful  an  invention.  It  has  been  extensively 
used,  but  the  mortality  in  its  wake  has  been  so  enormous  that  it  seems 
to  do  positive  harm.  It  has  been  condemned  by  the  committee  ap- 
pointed by  the  American  Gynaecological  Society  to  report  on  it.^^  It 
is  only  a  question  whether  the  mortality  which  has  followed  its  use 
was  due  to  the  fluid  or  to  the  curettage  that  preceded  the  injection. 

On  the  other  hand,  nuclein  seems  to  be  a  valuable  addition  to  our 
resources  for  combating  puerperal  infection.  This  is  a  substance  ob- 
tained from  yeast.  It  is  given  hypodermically  (ti^x — 60  centigrammes 
— twice  a  day,  increasing  by  ti^v — 30  centigrammes — daily)  or  by 
the  mouth  (^ss  to  si— from  2  to  4  grammes).  These  doses  refer  to 
the  "nuclein  solution"  prepared  by  Park,  Davis  &  Co.  The  use 
of  nuclein  is  rational  in  so  far  as  it  produces  an  artificial  leucocy- 
tosis,  and  we  know  that  leucocytes  are  employed  in  the  household 
of  nature  to  engulf  microbes  and  render  them  harmless.  Nuclein  has 
a  good  effect  on  the  secretions,  ulcers,  and  the  general  condition  of  the 
patient.  It  is  apt  to  cause  pain  in  the  bones,  especially  the  tibiae, 
which  disappears  within  a  week ;  and  in  so  serious  a  disease,  where 
the  patient's  life  is  at  stake,  such  a  drawback  cannot  carry  much 
weight  .^^ 

Hypodermoclysis  is  also  well  worth  trying  (see  p.  581).  By  it  a 
large  amount  of  normal  salt  solution  is  pumped  into  the  circulatory 
system  and  eliminated  by  the  kidneys.  Thus  it  constitutes,  as  it  were, 
an  internal  bath,  by  which  obnoxious  substances  are  washed  out  of 
the  tissues.  By  combining  this  method  with  large  high  enemas  of 
salt  solution  or  soapsuds,  the  effect  is  increased. 

Instead  of  injecting  the  fluid  under  the  skin  it  may  be  injected 
into  a  vein,  which  has  a  more  prompt  effect. 

Atmocausis  has  been  used  in  a  successful  case.^^  It  is  certainly  an 
effective  way  of  disinfecting  the  uterine  cavity,  and  is  not  unlikely 
to  arrest  infection  if  applied  early. 

Hysterectomy  has  been  performed  with  the  aim  of  removing  the 
source  of  the  infection.  If  this  operation  is  to  help,  it  must  be  per- 
formed before  the  microbes  have  invaded  the  general  system,  or,  some- 
times, within  a  day  or  two  after  confinement.  At  that  time  it  is, 
however,  hardly  possible  to  foretell  whether  septicaemia  will  develop 


PUERPERAL   INFECTION.  735 

or  not,  so  that  we  may  say  that  there  is  great  danger  that  the  oper- 
ation either  will  be  performed  too  early  or  too  late.  A  patient  should 
certainly  not  be  mutilated  if  she  can  get  well  and  retain  her  internal 
genitals  for  further  functions  ;  and  when  infection  has  once  been  gen- 
eralized, so  serious  an  operation,  which  always  is  accompanied  by 
much  shock,  will  hardly  avert,  and  may  even  hasten  a  fatal  issue. 
The  writer's  personal  experience  with  hysterectomy  for  puerperal 
infection  does  not  warrant  him  in  recommending  it,  and  it  has  been 
condemned  by  the  above-mentioned  committee. 

Parametritis  and  Adenitis. — These  localizations  are  treated  with 
ice,  hot  douches,  opium,  and  later  the  Priessnitz  compress.  If  the 
resolution  is  unduly  slow,  the  groin  should  be  painted  with  tincture 
of  iodine  once  a  day  and  covered  with  a  piece  of  lint  soaked  in  this 
lotion  : 

R   Acidi  carbolici,   3  i  (4  grammes)  ; 
Glycerini, 
Aquae,  aa  §iij  (90  grammes). — M. 

This  prevents  the  skin  from  cracking,  allows  one  to  continue  the 
use  of  the  iodine,  and  favors  its  absorption. 

When  the  tenderness  has  subsided  sufficiently  to  allow  a  speculum 
to  be  introduced,  it  is  well  to  combine  the  painting  of  the  skin  with 
that  of  the  vault  of  the  vagina,  which  brings  the  iodine  nearer  to 
the  affected  part.  This  is  repeated  every  three  days.  As  tincture 
of  iodine  spreads  far,  and  smarts  in  the  vulva  and  on  the  skin, 
only  very  little  should  be  used.  It  is  best  applied  with  a  very 
small  pledget  of  absorbent  cotton,  and  the  superfluous  fluid  should 
be  wiped  off  before  it  trickles  down  into  the  sensitive  region. 

If  suppuration  occurs  the  ice-bag  should  be  changed  for  a  warm 
flaxseed-meal  poultice,  and  when  the  abscess  is  formed  it  should 
be  opened  from  the  vagina  or  above  Poupart's  ligament  or  in  both 
places.  If  there  is  any  doubt  about  the  presence  of  pus,  an  ex- 
ploratory aspiration  may  be  m.ade  through  the  vagina.  For  this 
purpose  a  common  hypodermic  syringe  is  too  short.  The  writer 
has  had  one  made  with  an  attachment,  which  is  quite  convenient 
both  for  aspirations  and  injections  into  the  tissues  above  the  vagina 
(Fig.  490). 

But  to  open  an  abscess  in  the  broad  ligament  is  not  so  simple 
a  matter  as  to  incise  a  felon.  The  operator  has  to  keep  clear  of 
the  ureter,  the  bladder,  vaginal  arteries,  the  uterine  artery,  and  even 
the  internal  iliac. 

If  the  affection  is  unilateral  an  incision  is  made  through  the 
vaginal  roof  in  a  slanting  direction  backward  and  outward  from  the 
place  where  a  transverse  Ime  drawn  through  the  os  strikes  the  side 


736 


ABNORMAL   PUERPERY. 


of  the  cervix.     Next  the  connective  tissue  is  separated  with  the  finger 
and  blunt  instruments  till  the    abscess  is  reached,  when  my  blunt 


Fig.  490. 


Exploratory  vaginal  aspirator. 


expanding  perforator  (Fig.  491)  is  thrust  into  it  and  opened  to  its 
full  extent  and  withdrawn.      The    cavity  is   then  washed   out  with 


Fig.  491. 


Garrigues's  blunt  expanding  perforator. 


plain  sterilized  water  and  a  soft-rubber  sky-rocket  drainage-tube  (Fig. 
492)  inserted  and  fastened  to  the  lips  of  the  opening  in  the  vagina 


Fig.  492. 


.^SJ 


Sky-rocket  drainage-tube. 


with  four  sutures.     If  the  abscess  is  small  it  is  enough  to  insert  a 
double  drainage-tube  with  cross-bar  (Fig.  493).      The  afferent  tube 


Fig.  493. 


Double  drainage-tube  with  cross-bar. 

should  be  thinner  than  the  efferent  and  without  side  holes.  These 
tubes  can  easily  be  improvised  by  sewing  pieces  of  rubber  tubing 
together.  They  should  be  cut  short  a  little  outside  of  the  vulva,  so 
that  the  cavity  can  be  kept  clean  by  daily  injections  with  some  anti- 


PUERPERAL   INFECTION.  737 

septic  fluid,  preferably  tincture  of  iodine,  a  teaspoonful  to  a  pint  of 
lukewarm  water. 

If  there  are  two  abscesses,  one  on  either  side,  it  is  better  to  make 
a  transverse  incision  behind  the  cervix  and  open  and  drain  them  as 
just  described.  If  the  abscess  is  found  in  front  between  the  uterus 
and  the  bladder,  which  is  rare,  the  transverse  incision  is  made  in  front 
of  the  cervix,  keeping  within  the  width  of  the  cervix.  The  bladder  is 
cautiously  separated  with  the  finger  and  the  abscess  opened  with  the 
hlunt  perforator. 

If  there  is  any  hemorrhage,  the  cavity  should  be  packed  with  iodo- 
form gauze,  and  the  drainage-tube  inserted  a  day  or  two  later. 

The  way  of  disinfecting  the  vagina  has  been  described  on  p.  567. 

As  a  rule,  the  opening  and  drainage  of  the  abscess  leads  to  recov- 
ery within  a  month ;  but  if  a  fistulous  tract  remains,  and  suppuration 
undermines  the  patient's  strength,  her  life  may,  perhaps,  still  be  saved 
jDy  vaginal  hysterectomy  with  or  without  salpingo-oophorectomy,  but 
this  is  likely  to  be  a  difficult  undertaking. 

If  the  abscess  points  above  Poupart's  ligament,  a  large  incision 
should  be  made  above  and  parallel  to  the  ligament,  cutting  layer  by 
layer.  When  an  opening  has  been  made  into  the  abscess  cavity,  a 
finger  is  inserted,  counter-pressure  made  from  the  vagina,  and  if  there 
is  not  too  much  intervening  tissue,  a  counter-opening  is  made  here, 
and  a  soft-rubber  drainage-tube  with  side  holes  drawn  through  both 
openings. 

If  the  suppuration  has  been  allowed  to  spread  widely,  incisions 
may  also  be  needed  above  the  middle  of  the  crest  of  the  ilium, — at 
Petit's  triangle, — and  higher  up  on  the  back. 

The  internal  treatment  is  the  same  as  stated  above. 

Lymphangeitis  and  Ltmphothrombosis. — The  external  lymphangeitis 
is  treated  with  compresses  dipped  into  a  lead-and-opium  wash : 

R   Tinct.  opii,   gss  (15  grammes)  ; 

Liq.  plumbi  subacetatis  diluti,  q.  s.  ad  §viii  (240  grammes). — M. 
Sig. — For  external  use. 

If  suppuration  occurs,  the  abscess  is  opened. 

Lymphotkrombosis  of  the  uterus  and  the  broad  ligaments  is  treated, 
like  the  inflammations,  with  ice-bags,  opiates,  saline  aperients,  quinine, 
alcohol,  and  the  special  antiseptic  remedies  enumerated  when  treating 
of  metritis. 

Salpingitis  and  Oophoritis. — If  we  infer  from  the  persistent  fever, 
the  pain,  the  swelling,  and  the  sensitiveness  on  pressure  that  abscesses 
have  formed  in  the  tubes  and  ovaries,  we  should  give  nature  plenty 
of  time  to  wall  off  the  inflamed  organs  from  the  peritoneal  cavity,  and 
then  they  should  be  opened  from  the  vagina  as  described  for  parame- 

47 


738  ABNORMAL   PUERPERY. 

tritis.  The  author  has  had  most  excellent  results  from  this  opera- 
tion, opening  as  many  as  five  pus  collections,  one  being  in  Douglas's 
pouch  and  one  in  each  tube  and  ovary.  But  he  has  also  had  failures 
through  the  eruption  of  general  septicaemia. 

According  to  Dr.  Leon  F.  Garrigues,-^  the  tube  and  ovary  may  be 
reached  by  separating  the  two  layers  of  the  broad  ligament  and 
punctured  without  opening  the  peritoneal  cavity. 

Abdominal  salpingo-oophorectomy  should  be  performed  only  in 
those  cases  in  which  the  appendages  are  situated  so  high  up  in  the 
abdomen  that  they  cannot  be  reached  from  the  vagina.  The  prog- 
nosis is  bad. 

Peritonitis. — Opinions  are  much  divided  as  to  the  advisability  of 
using  antiseptic  intra-uterine  injections  in  peritonitis.  The  author's 
practice  is  to  give  a  copious  one  in  the  beginning  of  the  disease,  but 
not  to  repeat  it.  The  idea  is  that  besides  the  microbes  that  have 
already  penetrated  into  the  depth  of  the  tissues  there  may  be  others 
on  the  surface  of  the  uterus,  which  may  be  removed  by  a  thor- 
ough washing-out.  He  has  never  seen  any  bad  effect  from  this 
procedure  and  believes  that  sometimes  it  was  beneficial. 

The  abdomen  is  covered  with  two  large  ice-bags,  the  weiglit  of 
which  may  be  diminished  by  suspending  them  to  a  cradle,  or,  what 
is  preferable,  with  an  ice-water  coil.  If  cold  is  contraindicated  (p. 
731),  a  thin  flaxseed-meal  poultice  or  a  flannel  stupe  should  be 
substituted. 

Opium  is  an  invaluable  remedy  in  peritonitis,  which  may  be  given 
in  what  would  seem  enormous  doses.  To  give  prompt  relief  a  quar- 
ter of  a  grain  of  morphine  is  injected  hypodermically  at  the  beginning 
and  followed  by  ^  or  J  grain  by  the  mouth  every  half  hour,  until  the 
patient  is  fully  under  the  influence  of  the  drug, — that  is  to  say,  free 
from  pain  and  yet  not  in  deeper  narcosis  than  that  she  can  easily  be 
aroused.  The  morphine  may  safely  be  given  until  the  respiration  is 
brought  down  to  14,  13,  and  even  12  per  minute. 

The  author  is  well  aware  of  the  warning  of  Lawson  Tait  against 
opiates  in  peritonitis  after  gynaecological  operations,  and  he  follows  his 
advice  to  move  the  bowels  with  saline  aperients ;  but,  in  his  opinion, 
this  method  should  not  be  applied  to  puerperal  peritonitis.  When  he 
was  a  student  the  treatment  with  senna  was  in  vogue,  and  the  recol- 
lection of  the  poor  tortured  women  has  left  an  indelible  impression 
on  his  memory.  Besides  that,  hardly  any  one  survived.  With  the 
opium  plan  he  has  saved  one-half  of  his  patients  affected  with  diffuse 
peritonitis,  and  if  they  die  he  has  at  least  the  satisfaction  of  rendering 
their  condition  comparatively  comfortable. 

If  morphine  has  too  depressing  an  effect,  especially  if  the  heart  is 
weak,  it  may  be  combined  with  atropine  : 


PUERPERAL   INFECTION.  739 

R   Atropinae  sulphatis,  gr.  I  (8  milligrammes)  ; 

Solutionis  morphinse  (Mageiidie),   ^ii  (8  grammes). — M. 
Sig. — From  four  to  eight  minims,  as  prescribed. 

This  may  be  given  in  the  same  dose  and  repeated  as  the  plain 
morphine  solution. 

Alcohol  should  likewise  be  given  in  very  large  doses — from  half 
an  ounce  to  an  ounce  of  strong  liquor — every  two  hours,  or  oftener. 
Quinine  is  given  in  the  dose  of  five  grains  every  four,  hours,  which  is 
the  time  it  needs  for  elimination,  so  that  the  patient  is  kept  steadily 
under  its  influence,  without  being  overpowered  by  large  single  doses. 

No  aperient  medicine  is  used.  The  bowels  generally  move  spon- 
taneously from  time  to  time,  and  if  they  do  not,  an  enema  is  given.  A 
small  amount  of  pure  glycerin  (^ii-si — from  8  to  30  grammes)  may  be 
injected,  or  a  quart  of  flaxseed-meal  infusion  with  a  tablespoonful  of 
castor  oil  and  a  teaspoonful  of  oil  of  turpentine,  or,  best  of  all,  an 
ox-gall  enema  (inspissated  ox-gall,  a  teaspoonful,  or  fresh  gall,  a  table- 
spoonful  ;  glycerin  and  castor  oil,  a  tablespoonful  of  each  ;  table  salt,  a 
heaping  teaspoonful ;  and  flaxseed-meal  tea,  a  tablespoonful  to  a  quart, 
strained). 

The  injection  of  creosote  alone  or  mixed  with  equal  parts  of  cam- 
phorated oil,  beginning  with  8  minims  (50  centigrammes)  of  creosote 
morning  and  evening  and  gradually  increasing  the  dose  till  45  minims 
(3  grammes)  of  creosote  are  given  daily,  has  been  much  praised.  It 
is  injected  deeply  into  the  gluteal  region  or  the  muscles  of  the  spine. 
The  injection  is,  however,  very  painful,  and  has  not  had  any  appre- 
ciable effect  in  the  writer's  hands. 

Occasionally  the  above-mentioned  tonics  for  the  heart  and  respira- 
tion are  given.  For  the  vomiting  cocaine  and  hydrocyanic  acid  are 
the  best  remedies.  The  former  is  given  hypodermically  or  by  the 
mouth  (gr.  ^  every  2  hours) ;  the  latter,  by  the  mouth,  according  to 
this  formula : 

R    Acidi  hydrocyanici  diluti,   gss  (2  grammes)  ; 
Acidi  citrici, 

Sodii  bicarbonatis,  aa  ^ii  (8  grammes)  ; 
Syrupi  rubi  idasi,   ^ss  (15  grammes)  ; 
Aqua?  destillatae,  q.  s.  ad  ^vi  (180  grammes). — M. 
Sig. — A  tablespoonful  every  1,  2,  or  3  hours. 

An  ice-bag  placed  over  the  pit  of  the  stomach  is  also  useful. 

The  diet  is  strictly  fluid,  and  consists  only  of  beef  tea,  milk,  and 
oatmeal  gruel  or  farina.  But,  as  it  is  quite  important  to  feed  the 
patient,  the  beef  tea  must  not  be  water  with  a  flavor  of  osmazome  and 
without  nourishing  quality.  Good  beef  tea  may  be  obtained  by  pour- 
ing a  pint  of  cold  water  mixed  with  one  or  two  teaspoonfuls  of  dilute 


740  ABNORMAL    PUERPERY. 

hydrochloric  acid  on  a  pound  of  minced  lean  beef  of  superior  quality. 
It  is  left  for  an  hour  and  a  half  and  stirred  about  every  quarter  of  an 
hour.  Then  it  is  put  over  the  fire  until  it  reaches  the  boiling-point, 
strained,  and  taken  warm  or  cold,  after  addition  of  a  little  salt,  two 
ounces  at  a  time.  Another  way  is  to  let  the  beef,  the  water,  and  the 
muriatic  acid  stand  on  ice,  press  it  repeatedly  with  a  wooden  spoon, 
strain  it,  and  keep  it  on  ice.  About  two  ounces  should  be  given  every 
two  hours.  If  the  patient  vomits  so  large  a  bulk,  the  beef  may  be 
boiled  in  a  closed  bottle  without  any  water,  but  immersed  in  a  water- 
batli.  Of  this  strong  juice  a  few  teaspoonfuls  are  given  at  a  time. 
Strong  beef  juice  may  also  be  obtained  by  broiling  a  slice  of  beef  and 
squeezing  it  in  an  apparatus  made  for  that  purpose  and  found  in  hard- 
ware stores.  These  home-made  beef  juices  and  beef  teas  are  much 
to  be  preferred  to  the  different  extracts  found  on  the  market,  and 
which  chiefly  contain  creatinin  and  only  little  albuminoids. 

To  give  an  idea  of  the  amount  of  morphine,  alcohol,  and  food  that 
may  be  taken,  the  author  may  mention  that  one  of  his  patients  who 
recovered  consumed  in  twenty-three  days  216  grains  (14.4  grammes) 
of  morphine,  228  ounces  (6840  grammes)  of  whiskey,  1078  ounces 
(32,340  grammes)  of  milk,  and  418  ounces  (12,540  grammes)  of  beef 
tea,  which  makes  an  average  of  9  grains  (58  centigrammes)  of  mor- 
phine, 9|  ounces  (285  grammes)  of  whiskey,  45  ounces  (1350  grammes) 
of  milk,  and  7^  ounces  (225  grammes)  of  beef  tea  in  twenty-four  hours. 
The  greatest  amount  of  morphine  administered  in  one  day  was  13f 
grains  (880  milligrammes). 

No  antipyretics  should  be  prescribed.  They  only  mask  the  con- 
dition and  weaken  the  patient.  The  quinine  is  given  only  in  small 
doses  that  have  no  influence  on  the  temperature. 

The  best  way  of  reducing  temperature  is  by  the  external  applica- 
tion of  cold.  In  addition  to  the  ice-bags  or  ice-coils  on  the  abdomen 
an  ice-cap  may  be  laid  on  the  head.  Some  are  made  particularly  for 
this  purpose  in  the  shape  of  a  helmet.  It  is  refreshing  to  the  patient 
to  be  washed  all  over  the  body  with  equal  parts  of  alcohol  and  water, 
but  it  has  little  influence  on  the  internal  temperature.  Real  refrigera- 
tion may  be  obtained  by  Kibbee's  fever-cot,  the  cold  pack,  or  cold 
baths. 

The  fever-cot  consists  of  a  wooden  frame  with  a  network  of  cord, 
under  which  is  a  rubber  sheet  forming  an  inclined  gutter.  At  the 
lower  end  is  placed  a  pail.  A  folded  blanket  is  laid  over  the  netting 
to  protect  the  skin  against  being  cut  by  the  cords,  and  a  rubber-cov- 
ered pillow  is  laid  at  the  head  of  the  cot.  A  folded  sheet  is  laid  from 
side  to  side  over  th.e  middle  of  the  cot,  wide  enough  to  reach  from  the 
patient's  armpits  to  her  trochanters.  Her  clothes  are  drawn  up,  and 
the  legs  are  covered  with  woollen  stockings  and  a  blanket.    Hot-water 


PUERPERAL   INFECTION.  741 

bottles  may  even  be  placed  against  the  soles  of  her  feet.  The  sheet  is 
folded  over  her  abdomen  and  chest,  and  water  is  poured  gently  over 
it  with  a  pitcher.  The  water  should  at  first  be  from  85°  to  90°  F., 
but  is  gradually  made  colder,  down  to  80°  or  even  75°  F.  This  pro- 
cedure is  continued  for  a  quarter  of  an  hour,  when  the  sheet  is  let 
down  and  the  patient  is  covered  up.  At  the  end  of  each  hour  the 
aspersion  may  be  repeated,  if  there  is  a  new  rise  in  temperature.  The 
great  advantage  of  this  contrivance  is  that  the  patient  need  not  be 
moved  at  all. 

When  the  fever-cot  is  not  obtainable,  the  cold  pack  may  be  sub- 
stituted. For  this  purpose  two  beds  should  be  prepared,  each 
covered  with  sheet-rubber  or  oil-cloth  and  a  blanket.  Over  the 
blanket  is  placed  a  sheet  wrung  out  of  cold  water.  The  patient  is 
placed  on  the  sheet,  which  is  folded  over  her  from  the  neck  down, 
except  the  feet.  If  circulation  is  bad,  hot  water  bags  or  bottles 
may  be  placed  against  the  soles  of  the  feet.  The  patient  may  be 
covered  with  a  blanket  or  two  tucked  in  all  around  her  body.  After 
ten  minutes  she  is  removed  to  the  other  bed,  where  the  same  pro- 
cedure is  gone  through.  Five  or  six  packs  may  be  needed  to  reduce 
the  temperature  to  the  point  desired. 

If  a  bath-tub  can  be  procured,  it  is  preferable,  for  the  cold  hath 
does  not  necessitate  so  much  handling.  The  patient  may  be  im- 
mersed in  the  sheet  of  her  bed  into  a  bath  slightly  below  blood-tem- 
perature. By  withdrawing  warm  water  and  adding  cold  the  temper- 
ature of  the  bath  is  gradually  brought  down  to  80°  F.  It  is  advis- 
able to  give  a  tablespoonful  of  brandy  immediately  before  the  bath, 
and  she  should  be  carefully  watched  in  the  bath,  and  taken  out  at  the 
slightest  sign  of  collapse.  If  she  stands  it  well,  she  may  remain  in  it 
for  fifteen  or  twenty  minutes. 

Laparotomy  has  been  performed  in  several  cases,  the  fluid  and 
fibrinous  clots  turned  out,  the  cavity  washed  out  with  normal  salt 
solution  and  wiped  with  peroxide  of  hydrogen,  and  gauze-drains  left 
for  escape  of  gas  or  fluid,  but  the  results  have  not  been  very  en- 
couraging. 

If  the  peritonitis  is  due  to  rupture  of  an  abscess,  the  abdomen 
should  be  opened  at  once,  cleaned,  and  drained. 

It  has  also  been  recommended  to  make  a  wide  transverse  incision 
behind  the  uterus  and  leave  a  Mikulicz  tampon  in  the  pelvis. 

When  the  patient  survives  the  acute  stage  and  the  exudation 
becomes  encysted,  the  abscess  should  always  be  opened  and  drained 
in  a  way  similar  to  that  described  for  local  peritonitis. 

Pleurisy. — If  the  pleura  becomes  inflamed,  an  ice-bag  should  be 
applied  to  the  chest ;  or,  if  cold  is  not  well  borne,  or  the  seat  of  the 
inflammation  is  on  the  back,  that  side  of  the  chest  should  be  covered 


742  ABNORMAL   PUERPERY. 

with  a  flaxseed-meal  poultice  or  a  piece  of  spongiopiUne — a  gutta- 
perclia-covered  sheet  of  felt,  which  only  needs  dipping  into  hot  water 
and  keeps  nicely  warm.  Antiphlogistine  might  also  be  tried.  It  is  a 
putty-like  combination  of  glycerin,  boric  acid,  salicylic  acid,  iron  car- 
bonate, peppermint,  gaultheria,  eucalyptus,  iodine,  and  dehydrated 
silicate  of  aluminum  and  magnesium.  It  is  warmed  and  smeared 
directly  on  the  skin  in  a  layer  one-eighth  inch  thick,  covered  with  a 
jacket  of  cheesecloth  or  bandage,  and  left  in  place  for  twenty-four 
hours  before  it  is  renewed.  The  last-named  item  is  of  importance 
to  these  poor  patients,  who,  on  account  of  the  acute  pain,  shun  being 
moved  more  than  necessary. 

In  the  exudative  form  of  pleurisy,  the  skin  over  the  affected  part 
may  be  painted  with  tincture  of  iodine.  Internally  iodide  of  potas- 
sium and  diuretics  should  be  administered,  for  instance  : 

E    Tritici  repentis  radicis  decoctionis,   ^ss-^viii  (15-240  grammes)  ; 
Potassii  acetatis, 
Potassii  bitartratis, 

Potassii  citratis,  aa  ^i  (4  grammes). — M. 
Sig. — Shake  well.     A  tablespoonful  from  four  to  six  times  a  day. 

The  amount  of  fluid  is  rarely  so  large  that  thoracentesis  is  indi- 
cated. If  the  fluid  becomes  purulent  [empyema),  a  piece  of  a  rib 
should  be  excised,  and  the  cavity  washed  out  and  drained. 

Pneumonia. — When  pneumonia  develops,  the  above-mentioned 
warm  applications  should  be  made  to  the  chest.  Stimulants  and 
heart  tonics  are  highly  called  for.  A  favorite  prescription  of  the 
writer  is  the  following : 

R    Ammonii  carbonatis,   ^ii  (8  grammes). 
Div.  in  chart.  No.  xii. 
Sig. — No.  1.     One  powder  four  times  a  day. 

R    Acidi  citrici, 

Sacchari  albi,  aa  ^^ii  (8  grammes). 
Div.  in  chart.  No.  xii. 
Sig. — No.  2.     One  powder  four  times  a  day,  mixed  with  No.  1. 

Each  powder  is  dissolved  in  one-third  of  a  glassful  of  water,  and 
the  contents  poured  together  and  drunk  while  effervescing.  Since  the 
disease  is  known  to  be  due  to  a  specific  microbe,  the  pneumococcus, 
creosotal — that  is,  carbonate  of  creosote — is  much  used.  It  is  an  in- 
ternal antiseptic  which  is  largely  excreted  through  the  breath ;  from 
n^^xv  to  3i  (1-4  grammes)  may  be  given  in  capsules  four  times  a  day. 

Inhalation  of  oxygen  may  help  the  patient  to  ride  out  a  storm. 

Gravitation  of  blood  to  the  lowest  parts  of  the  lungs  should  be 
avoided  by  frequent  change  in  position.  If  oedema  supervenes,  dry 
cupping  should  be  used  on  the  chest  in  front  and  behind. 


PUERPERAL   INFECTION.  743 

Pericarditis  and  Endocarditis. — Pericarditis  is  treated  like  pleu- 
risy. 

Endocarditis  is  probably  beyond  our  therapeutic  resources,  but 
ice-bags  and  the  different  heart  tonics  are  to  be  prescribed,  even  if 
we  do  not  expect  much  help  from  them. 

Enteritis. — The  inflammation  of  the  mucous  membrane  of  the 
intestine  and  the  accompanying  offensive  diarrhoea  are  treated  with 
internal  disinfectants.     Pure  carbolic  acid  may  be  given  : 

R    Acidi  carbolici  purissimi,  n^xvi  (1  gramme)  ; 
Mucil.  acaciae, 

Syrupi  aurantii,  aa  ^ss  (15  grammes)  ; 
Aquae  dest. ,  q.  s.  ad  ^viii  (240  grammes). — M. 
Sig. — A  tablespoonful  every  hour. 

It  may  be  combined  with  liquor  iodi  compositus,  in  the  same  dose. 
Salol  or  salophen,  gr.  v  (30  centigrammes)  every  two  hours,  and 
naphtalin,  gr.  ij-vii  (from  10  to  35  centigrammes)  every  two  hours, 
are  also  useful.  Warm  enemas  with  starch  (a  teaspoonful)  and  lau- 
danum (25  drops)  are  very  grateful  when  the  patient  suffers  from 
tenesmus.  The  addition  of  a  heaping  teaspoonful  of  subnitrate  of 
bismuth  has  a  beneficial  effect  both  as  germicide  and  astringent. 

Hepatitis. — The  inflammation  of  the  liver  is  treated  with  an  ice- 
bag  or  warm  stupes  and  the  internal  administration  of  calomel. 

Nephritis. — When  the  kidneys  are  affected,  a  flaxseed-meal  poul- 
tice or  a  quilted  muslin  bag  containing  digitalis  leaves  and  dipped  in 
hot  water  should  be  placed  under  the  loin.  Diuretics  should  be  given 
(see  Pleurisy).  Small  doses  of  chloral  (gr.  xv-xx — from  1  to  1.25 
grammes — from  one  to  three  times  a  day)  diminish  the  secretion  of 
albumin.  Tinctura  ferri  chloridi  (n^xv-xx — from  1  to  1.25  grammes) 
is  a  tonic,  astringent,  and  antiseptic.  Warm  baths  have  also  a  good 
effect. 

If  uraemic  symptoms  appear,  elimination  of  the  poison  through 
the  bowels  and  the  skin  should  be  favored.  For  this  purpose  drastic 
purgatives  are  used.  Croton-oil  (|  drop  every  half-hour,  2  drops  in 
all)  may  be  given  in  almond  oil,  bread-pill,  or,  if  the  patient  cannot 
swallow,  in  butter  rubbed  on  the  tongue.  Common  elaterium  is  given 
in  doses  of  l-^  grain  (from  15  to  30  milligrammes)  every  hour;  of 
Clutterbuck's  elaterium  ^  gr.  (8  milligrammes),  of  elaterin  yy— iV  grain 
(4-5  milligrammes),  and  of  gamboge  gr.  i  (6  centigrammes)  every  hour. 

The  best  way  of  producing  perspiration  is  with  tlie  hot-air  bath. 
An  alcohol  lamp  is  placed  under  a  chair,  an  open  umbrella  over  the 
patient's  abdomen,  and  a  water-proof  over  both.  But  as  perspira- 
tion is  weakening,  the  patient  should  be  watched,  and  at  all  events 
the  bath  should  not  be  prolonged  beyond  two  hours. 


744  ABNORMAL   PUERPERY. 

The  diet  should  consist  exclusively  of  milk  in  its  natural  state  or 
peptonized,  or  fermented  as  kumiss  or  zoolac,  all  of  which  are  given 
in  frequent,  small  quantities.  If  even  these  are  vomited,  recourse 
must  be  had  to  rectal  alimentation  with  Leube-Rosenthal's  solution  ; 
Rudisch's  beef-peptonoids ;  a  mixture  of  four  ounces  of  beef  and  one 
ounce  of  pancreas,  which  the  butchers  call  "  white  liver,"  finely 
chopped  and  diluted  with  water  until  it  can  pass  through  a  David- 
son's syringe ;  or  an  egg  beaten  up  with  four  ounces  of  milk,  with  or 
without  the  addition  of  an  ounce  of  whiskey. 

The  troublesome  vomiting  is  combated  with  cocaine,  hydrocyanic 
acid,  nux  vomica,  bismuth,  creosote,  carbolic  acid,  or  tincture  of 
iodine,  internally,  and  ice  or  a  warm  turpentine  stupe  applied  to  the 
pit  of  the  stomach. 

Encephalitis  and  Meningitis. — If  the  brain  or  its  envelopes  are 
affected,  there  is  little  hope  of  any  therapeutical  results.  The  head 
should  be  covered  with  an  ice-cap.  Ergot  and  liquor  barii  chloridi 
(ni  V — 30  centigrammes)  may  be  given  every  four  hours  with  the  aim 
of  contracting  the  blood-vessels.  Intravenous  injection  of  collargolum 
might  be  tried  in  order  to  counteract  the  work  of  the  microbes. 

Delirium^  restlessness,  and  insomnia  are  treated  with  bromides, 
chloral,  cannabis  indica,  opiates,  sulphonal,  trional,  hydrobromate  of 
hyoscine,  etc. 

Arthritis. — If  a  joint  is  affected,  it  should  be  immobihzed  by 
splints.  In  the  beginning  an  ice-bag  has  often  excellent  effect. 
Later,  tincture  of  iodine  and  fly-blisters  may  cause  a  valuable  revul- 
sion to  the  skin.  If  the  fluid  becomes  purulent,  it  should  be  drawn 
out  with  an  aspirator  and  the  joint  injected  with  carbolic  acid  (3  to  5 
per  cent.),  creolin  or  lysol  (2  per  cent.),  or  peroxide  of  hydrogen,  and 
if  that  does  not  check  the  inflammation,  the  joint  must  be  opened 
with  free  incisions.  During  the  after-treatment  great  care  should  be 
taken  to  move  the  joint  so  as  to  avoid  ankylosis. 

Skin  Diseases. — The  eruptions  that  appear  on  the  skin  hardly  call 
for  special  treatment.  If  they  itch,  considerable  relief  may  be  afforded 
by  washing  them  with  this  lotion : 

E   Acidi  carbolici,    ^ss  (2  grammes)  ; 
Alcoholis, 

Glycerini,   aa  ^ss  (15  grammes)  ; 
Aquae,  q.  s.    ad    gvi  (280  grammes). — M. 

Bed-sores  should  be  zealously  avoided,  and,  if  they  appear,  treated 
most  carefully.  As  soon  as  the  skin  becomes  red  over  the  sacrum,  the 
trochanters,  the  heels,  or  the  shoulder-blades,  soft  pillows  should  be 
put  under  the  threatened  places.  An  inflatable  rubber  ring  is  placed 
under  the  breech.     Large  air-filled  pessaries  may  be  used  to  protect 


PUERPERAL    INFECTION.  745 

the  heels,  or  rings  may  be  made  by  winding  a  strip  of  muslin  around 
a  wad  of  cotton,  wool,  or  oakum.  The  red  spot  should  be  bathed 
frequently  with  lead-water.  The  skin  should  not  be  rubbed,  but  a 
soft  cloth  pressed  against  it  to  dry  it,  and  then  it  should  be  dusted 
with 

R    Zinci  oxidi,  ^ii  (8  grammes)  ; 
Amyli,  5!!  (60  grammes). — M. 

If  an  excoriation  forms,  it  should  be  dressed  with  lint  soaked  in 
glycerite  of  tannin  (gi  to  si — 4  grammes  to  30  grammes),  with  zinc 
ointment,  or  the  above-mentioned  ointment  with  iodoform  and  balsam 
of  Peru  (p.  729). 

If  gangrene  develops,  the  dead  tissue  should  be  cut  away  as  soon 
as  a  line  of  demarcation  is  formed,  and  the  sore  should  be  covered 
with  hnt  soaked  in  camphor  emulsion  : 

R    CamjihorEe,  §ss  (15  grammes)  ; 

Mucilaginis  acaciae,  ^  i  (30  grammes)  ; 
Aquae,  q.  s.  ad  ^v  (150  grammes). — M. 
Sig. — Shake  well.     For  external  use. 

When  once  the  hole  is  filled  by  granulation,  the  above-named  milder 
applications  may  be  substituted. 

In  severe  cases  much  benefit  may  be  derived  from  placing  the 
patient  on  a  water  mattress,  which  adapts  itself  perfectly  to  the  body 
and  facilitates  all  movements  by  the  ease  with  which  the  water  flows 
from  one  part  to  the  other. 

Phlebitis. — 1.  Common  phlebitis  of  the  legs  and  phlegmasia  alba 
dolens  are  treated  by  raising  the  extremity,  so  as  to  favor  reflux.  The 
affected  part  should  be  painted  once  daily  with  tincture  of  iodine  along 
the  inflamed  vein,  covered  with  cotton  batting,  and  slightly  com- 
pressed with  roller  bandages.  In  protracted  cases  blue  ointment  may 
be  substituted  for  the  iodine,  but  as  there  is  danger  of  loosening  a 
thrombus,  which  would  form  an  embolus,  the  ointment  should  be 
melted  with  oil  and  painted  on  the  skin  and  not  rubbed  in.  The 
severe  pain  in  phlegmasia  demands  a  free  use  of  opiates.  As  there 
is  great  tendency  to  relapse,  the  patient  should  be  kept  in  the  recum- 
bent position  as  much  as  two  weeks  after  the  swelling  has  subsided. 

2.  Uterine  phlebitis  calls  for  all  the  remedies  mentioned  above, 
especially  vaginal  douches,  ice-bags  or  stupes,  alcohol,  quinine,  heart 
tonics,  internal  antiseptics,  hypodermoclysis,  or  venous  injection  of 
normal  salt  solution,  and  refrigerants.  The  different  locahzations 
must  be  followed  up  and  treated  as  stated  above. 

With  some  obstetricians  hysterectomy  is  more  indicated  when  the 
diagnosis  of  uterine  phlebitis  can  be  made  than  in  any  other  condi- 


746  ABNORMAL    PUERPERY. 

tion.  As  a  rule,  the  operation  can  be  performed  from  the  vagina, 
which  operation  has  a  somewhat  better  prognosis  tlian  abdominal 
hysterectomy.  With  regard  to  the  technique  in  the  abdominal  section 
the  reader  is  referred  to  the  above-described  operation  (p.  675). 

The  vaginal  hysterectomy  may  be  performed  by  the  ligature  or 
clamp  method,  preferably  the  latter,  since  it  is  more  expeditious.^ 

Local  abscesses  should  be  opened  and  dressed,  and  subfascial 
suppuration  demands  several  long  and  deep  incisions  and  drainage. 

AcuTEST  Septicemia. — In  cases  where  the  whole  system  is  over- 
whelmed before  localizations  have  time  to  form,  it  goes  without  say- 
ing that  therapeutics  are  almost  powerless.  Still,  the  obstetrician  will 
stand  by  his  patient  and  do  all  he  can  to  help  her  to  resist  the 
formidable  onset  of  destructive  agents,  according  to  the  principles  iaid 
down  in  the  preceding  pages,  especially  prescribing  internal  antisep- 
tics, tonics,  and  stimulants.  A  French  physician  claims  great  success 
in  such  cases  by  the  hypodermic  injection  of  oil  of  turpentine  in  doses 
of  K  XV  (1  gramme).  It  forms  an  abscess,  and  may  be  repeated  in 
several  places.^^ 

Looking  back  over  the  whole  field  and  supplementing  his  own 
experience  with  a  somewhat  extended  scrutiny  of  literary  records,  the 
author  is  of  the  opinion  that  puerperal  infection  is  chiefly  a  medical 
disease,  and  that  surgical  interference  probably  has  done  more  harm 
than  good  in  trying  to  comibat  it.  Both  from  America  and  from 
abroad  we  have  reports  of  series  of  cases,  in  which  bacteriological 
examination  showed  the  presence  of  streptococci,  which  were  only 
treated  with  stimulating  and  tonic  drugs  and  nutritious  food,  and  in 
which  the  mortality  was  only  4  per  cent,  or  a  fraction  more.^" 

In  the  discussion  referred  to  above  on  "  puerperal  fever,"  which 
took  place  at  the  meeting  of  the  German  Gynaecological  Society  in 
Berlin,  in  May,  1899,  the  different  speakers  also  reported  their  mor- 
tality as  being  between  4  and  5  per  cent.,  although  they  differed  widely 
in  treatment.  This  can  then  probably  be  looked  upon  as  the  inherent 
mortality  with  good  medical  treatment. 

REFERENCES. 

1.  Kroenig,  Centralbl.  f.  Gyniik.,  1899,  p.  697. 

2.  Burkhardt,  ibid.,  p.  1274. 

3.  Koblanck,  ibid.,  p.  1383. 

4.  Vahle,  ' '  Das  bakteriologische  Verhalten  des  Scheidensekrets  Neugeborner, ' ' 
Zeitsch.  f.  Geburtshiilfe  und  GynakoL,  a'oI.  xxxii.,  No.  3. 

5.  Kronig,  Centralbl.  f.  Gynak.,  1899,  p.  679. 

6.  Oliver  Wendell  Holmes,  "  Contagiousness  of  Puerperal  Fever,"  New  Eng- 
land Quarterly  Journal,  1843.' 

7.  Robert  P.  Harris,  Amer.  Jour.  Med.  Sci.,  April,  1875,  p.  474. 

^  Garrigues,  Diseases  of  Women,  third  ed.,  pp.  510  and  513. 


DISEASES   OF   THE    UTERUS.  747 

8.  Siredey,  Les  Maladies  puerperales,  Paris,  1884,  p.  99. 

9.  Ibid.,  p.  98. 

10.  Fehling,  Archiv  f.  Gyniik.,  1888,  vol.  xxii.  p.  433. 

11.  Gustav  Braun,  Centralbl.  f.  Gyniik.,  1889,  vol.  xiii.  p.  636. 

12.  Fallen,  Trans.  N.  Y.  Obst.  Soc.,  1876-1878,  p.  78. 

13.  Depaul,  De  la  Fievre  puerperale,  Paris,  1858,  p.  31. 

14.  Bumm,    Centralbl.   f.    Gynak.,    1899,  vol.    xiii.  p.  723;  C.    Flugge,  ibid., 
1898,  vol.  xxii.  p.  350. 

15.  Busch,  Neue  Zeitschrift  f.  Geburtskunde,  vol.  xxxii.  No.  3. 

16.  Ahlfeld,  Centralbl.  f.  Gynak.,  1899,  p.  1195. 

17.  Czemetschka,  ibid.,  1895,  p.  231. 

18.  Schenk,  ibid.,  1898,  p.  980. 

19.  Lindenthal,  ibid.,  1899,  p.  679. 

20.  Ahlfeld,  Lehrbuch  der  Geburtshilfe,  2d  ed.,  Leipsic,  1898,  p.  551. 

21.  B.  Crede,  Die  medicinische  Woche,  Berlin,  May  28  and  June  3,  1901. 

22.  Trans.  Amer.  Gynajcol.  Soc,  1899,  vol.  xxiv.  p.  104.' 

23.  J.  Hofbauer,  Centralbl.  f.  Gynak.,  1896,  No.  17,  vol.  xx.  p.  441. 

24.  Oscar  Beuttner,  Centralbl.  f.  Gynak.,  1899,  p.  995. 

25.  L.  F.  Garrigues,   "  A  New  Method   for    Retroperitoneal  Drainage   of  Pyo- 
salpinx,"  Medical  News,  May  26,  1900. 

26.  Thierry,  Lyon  medical,  June  26,  1892. 

27.  J.  Whitridge  WiUiams,  Trans.  Amer.  Gyn.  Soc,  1899,  vol.  xxiv.  p.  97. 


CHAPTER   II. 

DISEASES  OF  THE  UTERUS. 

§  1.  Subinvolution  of  the  Uterus. — Subinvolution  means  the 
condition  in  whicli  the  uterus  after  childbirth  remains  of  larger  size 
than  normal. 

We  have  seen  (p.  228)  that  the  uterus  the  day  after  confinement 
ordinarily  is  found  some%vhat  and  even  as  much  as  an  inch  above  the 
umbilicus,  and  that  it  henceforth  diminishes  steadily  and  sinks  down 
into  the  pelvis.  The  time  that  elapses  before  the  uterus  regains  its 
normal  depth  varies  from  four  to  twelve  weeks,  and  this  process  of 
involution  occupies  in  most  cases  six  to  ten  weeks.  The  depth  of  the 
uterus  can  only  be  measured  with  sounds,  which  has  been  done  in  the 
interest  of  science,  but  from  which  the  practitioner  should  absolutely 
refrain.  Practically  we  may  say  that  involution  progresses  satisfac- 
torily if  the  uterus  within  two  weeks  leaves  the  anterior  wall  of  the 
abdomen  and  sinks  down  into  the  true  pelvis.  In  most  cases  this 
takes  nine  days,  and  that  is  probably  the  origin  of  the  routine  practice 
of  midwives  and  most  physicians  in  keeping  the  patient  in  bed  for  that 
length  of  time,  but  I  have  seen  involution  in  primiparoe  progress  thus 
far  in  five  days.  In  judging  of  the  height  of  the  uterus,  it  is  to  be 
remembered  that  the  fundus  in  the  unimpregnated,   living  woman 


748  ABNORMAL    PUERPERY. 

normally  reaches  a  little  above  the  plane  of  the  brim  of  the  pelvis, 
which  must  not  be  confomided  with  a  horizontal  plane  passing  through 
the  upper  end  of  the  symphysis  when  she  stands/ 

The  immediate  cause  of  the  diminution  in  the  size  of  the  womb  is 
muscular  contraction,  which  presses  out  glycogen  and  blood  from  the 
wall  of  the  uterus  ;  and  from  the  second  day  fatty  degeneration,  lique- 
faction, and  absorption  take  place. 

Anything  that  interferes  with  the  contraction  and  retraction  and 
the  normal  metabohsm  in  the  muscle-cells,  any  active  congestion  or 
passive  stasis  of  blood,  may  therefore  become  a  cause  of  subinvolu- 
tion. There  may  be  retention  of  lochia,  a  blood-clot,  a  piece  of  the 
placenta,  or  part  of  the  membranes.  There  may  be  small  fibroids 
interspersed  in  the  muscular  tissue  of  the  uterus. 

Women  who  do  not  nurse  are  more  lialDle  to  subinvolution,  the 
sucking  of  the  child  having  a  direct  effect  on  uterine  contractions. 
Women  who  lead  a  sedentary  life,  who  do  not  use  their  muscles,  who 
have  flabby  flesh,  and  who  are  anaemic  are  more  likely  to  have  a 
defective  involution  than  those  who  have  more  active  habits.  The 
writer  has  called  particular  attention  to  the  value  of  bicycling  in 
developing  the  round  ligaments  of  the  uterus  and  thus  preventing  dis- 
placements and  insuring  the  right  direction  of  the  fcetus  towards  the 
brim  of  the  pelvis  during  labor.^  Irregular  tightening  of  the  abdom- 
inal binder,  an  overfilled  bladder,  or  a  loaded  intestine  may  interfere 
with  the  free  circulation  in  the  uterus.  The  same  may  in  a  more  per- 
manent and  less  remediable  way  be  due  to  heart  disease,  liver  com- 
plaint, or  chronic  kidney  trouble.  Premature  getting  up  after  child- 
birth is  a  common  cause  of  subinvolution.  The  uterus  at  that  time 
is  large,  heavy,  flabby,  anteverted,  and  anteflexed.  All  the  surround- 
ing parts  destined  to  support  it  are  distended,  soft,  and  yielding. 
When  the  woman  occupies  a  recumbent  position,  gravitation  works 
favorably  in  counterbalancing  these  conditions  ;  but  when  she  resumes 
the  sitting  and  erect  posture,  gravity  works  under  the  most  favor- 
able angle,  namely,  perpendicularly  on  the  long  axis  of  the  uterus, 
getting  a  good  purchase  by  taking  hold  of  the  enlarged  body  of  the 
uterus,  which  forms  the  long  arm  of  a  lever,  placed  horizontally, 
while  the  cervix  represents  the  short  arm  of  the  same,  placed  almost 
perpendicularly.  Premature  resumption  of  sexual  intercourse  deter- 
mines a  rush  of  blood  to  the  internal  genitals.  The  high  forceps  oper- 
ation or  version  often  retards  involution.  Narrowness  of  the  pelvis 
may  have  the  same  effect,  even  if  no  operation  has  been  performed. 
The  decidua  may  grow  unduly  or  a  fibrinous  polypus  form  on  the 
placental   site.     The    endometrium    may   become    the    site    of  both 

^  Garrigues,  Diseases  of  Women,  third  ed. ,  p.  54. 

^  Garrigues,    "Woman  and  the  Bicycle."  The  Forum,  January,  1896. 


DISEASES    OF   THE    UTERUS.  749 

glandular  and  interstitial  hypertrophy.  Often  a  laceration  of  the 
cervix  gives  rise  to  inflammatory  action  in  the  parametrimii.  Peri- 
tonitic  adhesions  may  mechanically  prevent  the  involution.  Retro- 
version and  retroflexion  always  cause  venous  stasis. 

In  the  course  of  time  subinvolution  leads  to  the  formation  of 
connective  tissue  in  the  uterus,  which  results  in  undue  hardness, 
often  produces  the  symptoms  of  chronic  metritis,  leaves  the  uterus  in 
a  weakened  condition  for  future  labors,  and  may  even  predispose  to 
its  rupture. 

During  the  lying-in  period  the  lochia  remain  red  longer  than 
normal  or  become  red  again  after  having  been  yellow. 

Subinvolution  need  not  be  limited  to  the  uterus.  A  similar  de- 
fective return  to  normal  conditions  may  be  found  in  the  ligaments, 
the  vagina,  or  the  abdominal  wall,  which  all  remain  too  large,  soft, 
and  flabby, — a  condition  which  favors  uterine  displacements,  prolapse 
of  the  vagina,  enteroptosis,  and  digestive  disturbances. 

The  treatment  is  chiefly  directed  against  the  cause,  but  should  also 
be  symptomatic.  The  patient  should  remain  in  bed  until  the  uterus 
is  properly  reduced  in  size.  If  there  is  a  retroversion  or  retro- 
flexion, the  uterus  should  be  manually  replaced  and  kept  in  posi- 
tion with  a  large  Emmet  or  Thomas  pessary,  for  which  smaller  ones 
are  substituted  later.  In  this  case  it  is  better  to  let  the  patient  sit 
up  part  of  the  day.  If  there  is  lochioraetra  or  a  retained  blood- 
clot,  the  uterus  should  be  manually  lifted  and  squeezed.  A  daily 
massage  and  faradization  or  the  application  of  the  galvanic  current 
may  also  be  beneficial  under  other  circumstances.  The  binder 
should  be  well  fitted  to  the  abdomen,  and  sometimes  a  special  pad 
may  be  inserted  to  advantage  between  it  and  the  uterus.  During  the 
lying-in  period  the  position  of  the  uterus  should  be  examined  daily 
and  any  deviation  obviated  by  postural  treatment.  If  the  mother  has 
the  baby  in  her  own  bed,  she  is  likely  to  turn  towards  it,  and  the 
fundus  will  fall  down  on  this  side.  If  the  bed  stands  with  one  side 
against  a  wall,  the  patient  will  turn  out  towards  the  room,  and  the 
uterus  will  fall  that  way.  Orders  must,  therefore,  be  given  every  day 
how  the  patient  shall  lie. 

If  the  patient  cannot  urinate,  the  urine  should  be  drawn  at  inter- 
vals not  exceeding  six  hours.  After  the  first  two  days  regular  evacu- 
ation of  the  bowels  should,  if  necessary,  be  insured  by  enemas  and 
aperients.  Large  hot  vaginal  douches  three  times  a  day  provoke  the 
uterus  to  contraction.  If  the  lochia  remain  red  too  long,  I  resume 
the  use  of  ergot,  or  give  a  decoction  of  cottonroot  bark.^  Iron  and 
alcohol  are  contraindicated,  since  they  increase  the  bloody  flow.    As  a 

^  Garrigues,  "The  Cottonroot  Bark  as  a  Uterine  Hiemostatic,"  The  Postgrad- 
uate, Jan.  1887,  vol.  ii.,  No.  2,  p.  117. 


750  ABNORMAL   PUERPERY. 

tonic  I  use  strychnine,  which  also  has  a  direct  effect  on  muscular  con- 
traction, mineral  acids,  and  bark  : 

R    Acidi  sulphuric!  diluti,  3ii  (8  grammes)  ; 
Extr.  cinchonas  co., 
Syr.  aurantii,  aa  gss  (15  grammes)  ; 
Aquae  destillataj,  c{.  s.  ad  ^viii  (240  grammes). — M. 
Sig. — Shake  well.     A  tablespoonfal  four  times  a  day. 

If  it  is  known  that  portions  of  placenta  or  membranes  remain  in 
the  uterus,  the  patient  should  be  anaesthetized,  the  cervix,  if  necessary, 
dilated,  one  or  two  fingers  introduced  into  the  cavity  with  counter- 
pressure  from  the  outside,  and  the  offending  object  removed.  As  to 
curettage,  I  do  not  deny  that  it  occasionally  may  be  very  useful ;  but, 
as  stated  above,  it  is  too  dangerous  shortly  after  delivery,  so  that  it 
should  only  be  employed  under  very  pressing  circumstances,  or  de- 
layed till  a  period  when  all  danger  of  puerperal  infection  is  passed. 

§  2.  Superinvolution  of  the  Uterus. —  Superinvolution  is  an  ab- 
normal atrophy  of  the  uterus  following  childbirth.  It  is  really  more 
a  gynsecological  than  an  obstetrical  disease,  since  it  hardly  will 
begin  in  the  short  period  the  woman  remains  in  the  hands  of  the  ob- 
stetrician. But  since  atrophy  often  originates  as  a  sequel  of  abortion 
or  childbirth,  we  shall  devote  a  few  lines  to  it  here. 

In  most  cases  the  whole  organ  shrinks  in  all  dimensions,  but,  oc- 
casionally, the  depth  of  the  uterine  cavity  may  remain  unchanged  and 
the  atrophy  shows  only  in  the  great  thinness  and  abnormal  softness 
of  the  walls  of  the  uterus. 

Etiology. — It  is  by  far  not  so  common  as  subinvolution.  It  is 
somewhat  more  frec[uent  after  abortion  than  after  childbirth.  It  is 
caused  by  loss  of  blood,  protracted  lactation,  a  rapid  succession  of 
pregnancies,  debilitating  diseases,  such  as  scarlet  fever,  tuberculosis, 
chlorosis,  syphilis,  diabetes,  Bright's  disease,  and  exophthalmic  goitre. 
Puerperal  insanity  is  not  rarely  accompanied  by  it. 

Symptoms. — It  is  characterized  by  amenorrhoea  and  secondary 
sterility.  Some  patients  complain  of  sacral  pain,  headache,  insomnia, 
mental  depression,  anorexia,  indigestion,  and  general  weakness. 

As  a  rule,  the  canal  is  much  shortened,  but  even  if  the  sound 
enters  to  the  normal  depth,  it  is  characteristic  that  the  knob  is  felt  with 
unusual  distinctness  through  the  abdominal  wall. 

The  prognosis  is  in  so  far  better  in  puerperal  cases  than  when 
atrophy  develops  from  other  causes,  as  the  condition,  when  of  puerpe- 
ral origin,  sometimes  is  only  transient. 

Treatment. — If  there  is  amenorrhoea,  the  practitioner  should  take 
care  not  to  prescribe  emmenagogues.  The  patient  should  have  a  rich 
albuminoid  diet  with  strong  red  wine.     If  she  nurses,  the  child  should 


DISEASES   OF   THE   UTERUS.  751 

be  weaned.  The  best  local  treatment  consists  in  the  application  of 
the  galvanic  current,  with  the  negative  pole  in  the  uterus.  Besides, 
the  patient  should  be  given  phosphorus,  protonuclein,  terraline,  and 
bitter  remedies. 

§  3.  Retention  of  Parts  of  the  Placenta  or  Membranes. — We 
have  seen  that  the  retention  of  parts  of  the  after-birth,  especially  the 
placenta,  may  give  rise  to  puerperal  infection  (p.  698).  We  have  also 
met  it  as  a  cause  of  subinvolution  (p.  748).  It  also  gives  rise  to  hem- 
orrhage. That  occurring  immediately  after  labor  has  been  discussed 
above  (p.  509).  But  we  may  have  hemorrhage  from  this  cause  oc- 
curring days  or  weeks  after  labor — so-called  secondary  post-partum 
hemorrhage.  A  large  part  of  the  placenta,  even  one-half  of  it,  may  be 
retained  and  expelled  in  the  course  of  the  first  day  without  much 
hemorrhage,  but  most  frequently  there  is  serious  or  even  fatal  loss  of 
blood.  Smaller  pieces  may  remain  in  the  uterus  for  a  week  or  two 
without  causing  any  hemorrhage,  but  it  is  sure  to  follow  earlier  or 
later.  Such  retention  may  happen  even  when  the  placenta  is  ex- 
pelled spontaneously,  and  it  is  not  unlikely  that  it  occurs  oftener 
when  it  is  expressed  soon  after  the  birth  of  the  child.  Sometimes 
the  retained  part  is  a  placenta  succenturiata,  the  membranes  being 
torn  off  in  its  circumference.  In  other  cases  there  may  have  been 
placentitis,  which  has  caused  an  abnormally  firm  connection  between 
the  placenta  and  the  uterus.  A  piece  of  placenta  may  remain  and 
become  covered  with  layers  of  fibrin,  forming  a  so-called  placental 
poll/pus.  Rarely  the  nucleus  is  formed  by  the  decidua  alone,  when 
the  formation  is  called  a  decidual.^  or  fibrinous,  pjolypus. 

These  polypi  are  much  more  common  after  abortion  than  after 
delivery  at  term,  and  may  then  not  make  their  appearance  before 
weeks  or  months  have  elapsed. 

At  term  labor  may  be  accompanied  by  hemorrhage,  or  may  be 
entirely  normal,  but  within  a  week,  or  oftener  two  or  three  weeks, 
there  follows  a  profuse  hemorrhage,  which  may  be  repeated. 

The  diagnosis  is  not  difficult,  because  the  internal  os,  which  gen- 
erally closes  within  twelve  days,  remains  open  longer  or  reopens. 
By  vaginal  examination  rarely  a  tumor  is  felt  hanging  down  into  the 
vagina.  More  frequently  it  is  found  inside  of  the  external  os,  and 
still  more  commonly  at  the  internal.  When  the  uterus  is  being 
pressed  well  down,  the  finger  can  be  carried  all  around  the  tumor, 
which  is  felt  attached  to  the  wall  of  the  uterus. 

The  prognosis  is  good  if  the  tumor  is  removed  early.  Otherwise 
it  may  give  rise  to  dangerous  hemorrhages  or  decomposition  of  the 
polypus,  followed  by  septic  endometritis  or  pyaemia. 

The  treatment  consists  in  the  removal  of  the  polypus,  which  in 
the  beginning  can  be  done  by  introducing  a  finger  and  pressing  it 


V02 


ABNORMAL    PUERPERY. 


against  the  pedicle,  ils  a  rule,  the  hemorrhage  stops  immediately. 
If  it  fails  to  do  so,  there  are  probably  other  masses  which  have  to  be 
removed.  After  the  removal  of  the  polypus  the  cavity  should  be 
^vashed  out  with  an  antiseptic  fluid.  If  the  case  comes  later  under 
treatment  it  may  be  necessary  to  dilate  the  cervix  and  use  the  curette. 

Ptetained  decidua  may  also  become  a  source  of  irritation,  in  con- 
sequence of  which  the  new-formed  endometrium  becomes  hyper- 
plastic, a  condition  designated  as  ■post-partum  endometritis. 

In  common  cases  of  retention  without  formation  of  a  polypus,  the 
treatment  is  similar.  A  finger  is  introduced  into  the  cavity  of  the 
uterus,  which  is  pressed  firmly  down,  and  the  remnant,  be  it  of  pla- 
centa or  the  ovum  or  hypertrophic  decidua.  scraped  off  with  the  nail, 
and  then  the  uterus  is  washed  out. 

§  4.  Malignant  Tumor  of  Pregnancy. — Not  many  years  ago  it 
was  discovered  that  a  malignant  tumor  is  apt  to  appear  in  connection 
with  pregnancy.     Since  then  many  cases  have  been  published.     The 


Fig.  494. 


e^^ 


Deciduoma  malignmn.     (Sanger.)    a,  nest  of  decidual  cells;  6,  another  developing ;  c,  inter- 
muscular connective  tissue  ;  d,  muscle-fibres ;  e,  extravasated  blood. 

original  case  was  described  under  the  name  of  deciduoma  malignum 
(Fig.  494),  and  the  tumor  was  believed  to  be  a  kind  of  sarcoma  devel- 
oped from  the  decidua.  In  other  cases  it  was  found  to  be  composed 
of  syncytium  and  the  epithelial  cells  of  the  villi  of  the  chorion,  and  it 
Avas  called  chorio-epithelioma  malignum  sive  destruens,  for  which  later 
have  been  substituted  chorioma  and  syncytioma  (Fig.  495).  In  other 
cases,  again,  the  development  was  shown  to  begin  from  the  epithelium 
of  the  capillaries  of  the  decidua,  and  it  was  declared  to  be  an  endo- 
thelioma.    Some  pathologists  lay  the  chief  stress  upon  the  fetal  ele- 


DISEASES   OF   THE    UTERUS. 


753 


Fig.  495. 


Syvcvt 


Sij)ici/t 


ments  of  the  tumor  and  consequently  look  upon  it  as  a  disease  of  the 
ovum,  while  others  take  it  to  be  a  maternal  disease.  According  to 
this  latter  view  the  patient  had  a  fibrous  sarcoma  or  an  endothelioma 
before  she  became  pregnant,  and  the  admixture  of  fetal  elements  is 
only  an  accidental  complication,  which  may  take  place  or  may  not. 
The  presence  of  syncytium  is  not  enough  to  prove  the  fetal  origin, 
because  under  the  influence  of  pregnancy  other  cells,  especially  the 
epithelium  of  the  uterine  glands,  may 
take  a  syncytial  character. 

However  this  may  be,  the  fact 
remains  that  a  malignant  tumor 
sometimes  forms  or  increases  in  the 
uterus  in  connection  with  pregnancy. 
Exceptionally  it  starts  from  the  Fal- 
lopian tubes. 

Etiology. — It  is  found  in  young 
women  or  in  elderly  ones  who  have 
often  been  pregnant.  It  may  occur 
after  labor  at  term  or  abortion,  and 
is  especially  frequent  after  a  vesicu- 
lar mole. 

Symptoms. — The  disease  appears, 
as  a  rule,  within  a  few  weeks  or 
months  after  confinement,  abortion, 
or  the  expulsion  of  a  vesicular 
mole  ;  rarely  from  two  to  four  years 
later.  It  is  characterized  by  re- 
peated or  continuous  hemorrhage. 
The  patient  becomes  pale,  and  loses 
strength  and  flesh.  Nodules  may 
appear  in  the  vagina  which  exulcer- 
ate  (Fig.  496).  Even  without  that 
there  may  be  an  offensive  discharge 
from  the  uterus,  due  to  the  break- 
ing down  of  the  tumor.  The  uterus  is  somewhat  enlarged.  Metas- 
tases may  also  form  in  the  iliac  fossa,  in  the  gluteal  region,  the  ileum, 
the  liver,  the  spleen,  the  kidneys,  the  lungs,  or  the  brain. 

Prognosis. — If  left  to  itself  the  disease  ends  fatally  within  six  or 
seven  months.  On  the  other  hand,  if  the  uterus  is  extirpated  the 
patient  may  recover,  even  after  emboli  have  been  carried  to  tlie  lungs. 
This  is,  however,  only  possible  if  the  emboli  consist  exclusively  of 
villi  of  the  chorion  and  do  not  contain  sarcoma  cells,  saprophytes, 
or  pathogenic  microbes.  By  hysterectomy  one-third  of  the  patients 
affected  with  malignant  tumor  of  pregnancy  have  been  saved. 

48 


Chorio-epithelioma  malignum.  (Ulesco- 
Stroganowa. )  Syncijt.,  tissue  consisting  of 
syncytium ;  Ec,  ectoderma  cells,  or  chorion 
epithelium  ;  G,  giant  cells. 


754 


ABNORMAL    PUERPERY. 


Diagnosis. — The  repeated  hemorrhage,  the  fetid  discharge,  the 
pallor  of  a  patient  who  recently  has  given  birth  to  a  child  or  aborted 
or  expelled  a  vesicular  mole,  and  the  enlargement  of  the  uterus 
awaken  the  suspicion  that  a  malignant  tumor  is  developing  in  it.  But 
the  diagnosis  can  only  be  established  by  introducing  the  fmger,  feel- 


FiG.  496. 


Sagittal  section  through  the  pelvic  organs  of  a  patient  with  chorio-epithelioma  malignum. 
(Marchand. )  c,  cavity  of  the  uteras  ;  1 1,  malignant  tumors  in  the  body  of  the  uterus ;  v,  bladder ; 
0,  enlarged  cedematous  right  ovary ;  vx,  varicose  tumor  beside  the  ovary ;  /,  flmbrise ;  ex,  cervix, 
infiltrated  with  blood ;  r,  rectum ;  iv,  tv,  tumors  in  the  vagina ;  u,  urethra ;  s,  symphysis  pubis ; 
sp,  sphincter  ani  muscle ;  id,  ulceration  at  the  meatus  urinarius ;  ts,  sanguineous  tumor  between 
th'eurethra  and  the  pubic  arch  ;  cc,  corpora  cavernosa  clitoridis  ;  h,  hymen  ;  fc,  frsenum  clitoridis  ; 
Imaj,  labium  majus ;  Imin,  labium  minus. 

ing  soft  masses  in  the  cavity  of  the  uterus,  scraping  them  off  with 
the  curette,  and  examining  them  microscopically.  The  cervical  canal 
is  sometimes  sufficiently  open  to  allow  the  insertion  of  a  fmger.  If  not, 
it  must  be  dilated  by  coniform  and  expanding  dilators  (pp.  566,  567), 
or  if,  exceptionally,  these  do  not  give  sufficient  space  for  passing  the 
fmger,  the  cervix  must  be  opened  with  laminaria  tents,  which  are  dis- 


DISEASES   OF   THE    UTERUS.  755 

infected  by  soaking  them  for  a  minute  or  two  in  a  boiling  antiseptic 
fluid,  forming  tliem  to  suit  tlie  curvature  of  the  cervical  canal,  and 
transferring  them  to  cold  fluid,  when  they  at  once  become  hard  again. 
Immediately  before  introduction  they  are  lubricated  with  corrosive- 
sublimate  glycerin  (1 :  1000).  The  patient  is  placed  in  Sims's  posi- 
tion, the  cervical  portion  is  made  visible  with  a  Sims  speculum,  a  lip 
of  the  cervix  seized  with  bullet-forceps,  and  the  tent  pushed  in  with  a 
dressing-forceps. 

Treatment. — As  soon  as  the  diagnosis  is  made  the  uterus,  tubes, 
and  ovaries  should  be  removed  by  vaginal  hysterectomy,  and  also 
vaginal  nodules  cut  out,  if  present. 

§  5.  Secondary  Post-partum  Hemorrhage. — Secondary  hemor- 
rhage is  in  most  cases  due  to  the  late  detachment  of  retained  parts  of 
the  placenta  or  membranes,  and  has  been  mentioned  in  connection 
with  that  condition.     It  may  come  also  from  subinvolution. 

During  the  first  few  days  of  the  puerperium  hemorrhage  may  be 
caused  by  an  overfilled  bladder,  which  interferes  with  the  contraction 
of  the  uterus.  It  may  be  caused  also  by  emotions  or  too  early  getting 
up.  Wounds  in  the  cervix,  vagina,  or  vulva  may  be  torn  open.  A 
dangerous  hemorrhage  of  this  kind  may  occur  if  at  the  time  of  labor 
hemorrhage  from  deep  vaginal  tears  was  arrested  by  tamponade  or 
suture. 

Sometimes  the  cause  of  the  hemorrhage  is  to  be  found  in  the 
detachment  of  thrombi  from  veins  of  the  placental  site.  If  this  takes 
place  in  a  case  of  puerperal  infection  with  metrophlebitis,  the  loss  of 
blood  may  be  severe  and  dangerous. 

Treatment. — In  all  cases  of  secondary  hemorrhage  the  accoucheur 
should  try  to  locate  the  source.  Retained  parts  of  the  placenta  and 
the  membranes  should  be  removed,  as  described  above.  An  over- 
filled bladder  should  be  emptied  with  catheter,  and  accumulated 
lochia  squeezed  out  of  the  uterus.  Reopened  wounds  may  call  for 
tamponing  or  suture.  Bleeding  from  the  interior  of  an  empty  uterus 
may  be  checked  by  large  hot  intra-uterine  injections,  faradism,  ergot, 
adrenalin,  or  stypticin,  but  if  necessary  the  uterus  should  be  tam- 
poned with  iodoform  gauze  or  plain  sterile  gauze.  Under  all  circum- 
stances the  patient  should  be  kept  quietly  in  bed  until  all  danger  is 
passed.  She  should  have  a  light,  cool  diet,  and  her  bowels  should  be 
kept  open  with  saline  aperients. 

Thrombus.,  or  hwrnatoma.  of  the  vulva  or  vagina  in  the  puerperium 
has  been  described  in  treating  of  Abnormal  Labor  (p.  521). 

§  6.  Displacements. — Anteflexion. — We  have  seen  above  (p.  229) 
that  immediately  after  delivery  the  uterus  assumes  a  shape  of  marked 
anteflexion,  which  even  doubtless  is  one  of  the  means  by  which  nature 
prevents  post-partum  hemorrhage.     During  several  weeks  this  ante- 


756  ABNORMAL    PUERPERY. 

displacement  increases,  especially  during  the  sitting  and  erect  posi- 
tions, wherefore  we  have  recommended  that  the  patient  should  be 
kept  lying  in  bed  until  the  uterus  has  sunk  down  into  the  pelvic 
cavity.  The  physiological  antedisplacement  ceases  gradually,  and  the 
uterus  resumes  its  normal  place  and  shape  ;  but  if  the  patient  gets  up 
too  soon  and  exerts  herself  by  physical  labor,  the  normal  involution 
may  be  interfered  "s^ith  and  the  uterus  remain  permanently  enlarged 
and  anteflexed.  This  wih,  however,  first  show  itself  after  the  lying- 
in  period  is  finished,  and  belongs,  therefore,  rather  to  the  domain  of 
gyuEecology. 

The  angle  formed  between  the  body  and  the  neck  of  the  womb 
may  prevent  a  free  outflow  of  the  lochia,  which  accumulate  in  the 
uterus,  and  may  become  offensive.  The  decomposed  blood  may 
become  partially  reabsorbed,  and  give  rise  to  fever  and  even  to  a 
chill — saprcemic  fever.  Under-  such  circumstances  the  uterus  should 
be  hfted  up  and  sc^ueezed  and  the  blood  removed  from  the  vagina  by 
disinfecting  injections. 

Congenital  anteflexion  is  a  great  impediment  to  conception,  but 
if  the  woman  becomes  pregnant,  the  gradual  elevation  during  the 
period  of  pregnancy  has  an  excellent  effect  on  the  shape  of  the 
uterus.  It  is,  in  fact,  the  best  treatment,  and  often  results  in  a  per- 
manent cure. 

Retro^t:rsion  and  Retroflexiox. — While  anteflexion  is  normal 
after  childbirth,  any  retrodisplacement — retroversion  or  retroflex- 
ion— is  abnormal. 

If  the  patient  has  had  such  a  displacement  before  her  pregnancy, — 
and  it  seems  rather  to  facilitate  than  to  impede  conception, — it  "will 
nearly  always  be  reproduced  after  a  few  weeks. 

If  the  patient  remains  in  bed  for  weeks,  mere  gravity  is  apt  to 
cause  the  uterus  to  fall  backward ;  and  when  once  it  is  retroverted, 
the  pressure  of  the  abdominal  organs,  impinging  on  the  anterior  wall 
of  the  uterus  instead  of  on  the  posterior,  will  gradually  bend  the 
organ,  so  as  to  change  the  retroversion  into  a  retroflexion.  Retro- 
flexion has  been  found  as  early  as  the  end  of  the  first  week.  A  too 
large  pelvis,  premature  labor,  or  abortion  favors  the  developuient  of 
retroflexion. 

Retroversion  and  retroflexion  always  interfere  with  the  normal 
circulation  in  the  uterus.  Quite  commonly  the  lochia  therefore  be- 
come red  again.  Retrodisplacement  leads  also  to  lochiometra  and 
subinvolution,  and  should,  therefore,  always  be  treated  as  soon  as  dis- 
covered. It  is  so  much  more  desirable  to  make  the  discovery  at  an 
early  date,  as  the  lying-in  period,  when  all  the  tissues  are  soft  and 
flexible,  is  the  very  best  time  for  successful  treatment  of  the  retrodis- 
placement. 


DISEASES    OF   THE    UTERUS.  757 

Treatment. — Those  who  had  a  retroflexion  before  their  pregnancy 
should  not  He  on  their  back,  but  on  the  side  and  in  a  semi-prone 
position. 

When  the  uterus  falls  back,  the  patient  shouid  be  placed  in  Shns's 
position.  The  physician,  standing  behind  her,  mtroduces  the  index 
and  middle  finger  of  the  right  hand,  with  the  dorsal  surface  turned 
forward,  and  pressure  is  exercised  on  the  corpus  uteri  upward  and 
forward.  The  reposition  is  often  facilitated  by  directing  the  pressure 
towards  one  of  the  iliosacral  articulations,  where  there  is  more  space. 
If  the  fingers  are  not  long  enough,  a  cotton  ball  held  in  a  pair  of 
curved  forceps  may  be  substituted.  After  the  replacement  is  accom- 
plished, the  woman  should  remain  in  a  semi-prone  posture.  As  a 
rule,  it  is  better  to  introduce  a  large  Albert  Smith  pessary  in  order 
to  retain  the  uterus  in  place.  Ergot  or  one  of  the  preparations  made 
from  it  is  given  with  a  view  of  causing  the  uterus  to  contract  in  the 
position  into  which  it  has  been  brought  manually. 

Lateroflexion. — During  involution  the  uterus  may  also  become 
bent  laterally.  This  depends  exclusively  on  the  posture,  and  can 
easily  be  avoided  by  following  the  above-mentioned  practice  of  feel- 
ing for  the  fundus  every  day  and  giving  the  puerpera  directions  how 
she  shall  lie. 

Prolapse  of  the  Uterus  and  the  Vagina. — When  the  uterus  is 
displaced  backward,  it  no  longer  forms  an  angle  with  the  vagina,  but 
lies  with  its  long  axis  m  the  continuation  of  that  hollow  organ,  and 
will  by  mere  gravity  sink  down  into  it.  This  movement  is  facilitated 
by  the  relaxation  of  the  tissues  that  normally  hold  the  uterus  back, 
especially  the  sacro-uterine  ligaments,  and  by  the  lack  of  support 
from  below.  The  vagina  and  vulva  have  been  overstretched,  and, 
perhaps,  torn  by  the  passage  of  the  child.  At  the  same  time  there  is 
often  subinvolution  of  the  vaginal  wall,  which  makes  it  soft  and 
heavy.  The  surrounding  connective  tissue  has  lost  its  elasticity  and 
become  yielding.  The  anterior  wall  sustains  the  pressure  of  the  full 
bladder ;  the  posterior  is  pushed  forward  and  downward  by  faeces 
distending  the  rectum.  Thus  both  the  anterior  and  the  posterior 
wall  bulge  into  the  vagina  and  out  through  its  entrance.  The  lower 
part  of  the  vagina  is  invaginated  and  exercises  a  traction  on  the 
upper  part  and  on  the  uterus,  adding  another  factor  to  the  mechan- 
ism by  which  it  descends  and  prolapses. 

Through  an  exertion  the  prolapse  may  also  form  suddenly,  but 
the  slow  development  is  more  common. 

During  pregnancy  a  prolapsed  uterus  is  carried  upward  by  its 
increased  size  and  no  longer  finds  room  in  the  pelvis,  but  after  delivery 
the  prolapse  is  in  most  cases  more  pronounced  than  before.  It  can 
only  be  improved  if  through  inflammatory  disease  the  uterus  has  been 


758  ABNORMAL   PUERPERY. 

suspended  by  peritoneal  adhesions,  or  the  vagina  has  been  so  nar- 
rowed by  cicatrices  that  the  uterus  can  no  longer  pass  it. 

Minor  degrees  of  prolapse  may  be  ameliorated  by  astringents  used 
in  vaginal  injections  or  on  tampons.  The  uterus  should  be  replaced 
and  the  patient  occupy  a  semi-prone  position.  Later  it  should  be 
held  up  by  a  supporter,  or  after  complete  involution  fastened  in  an 
operative  way  ^  or  removed. 

Elevation. — The  puerperal  uterus  may  be  lifted  abnormally  by 
a  full  bladder.  The  patient  should  then  be  told  to  urinate  frequently, 
or,  if  she  is  unable  to  do  so,  the  urine  should  be  drawn  four  times  a 
day  or  pftener,  according  to  the  desire  felt  by  the  patient. 

Floating  Kidney. — Childbirth  is  the  chief  cause  of  movable  or 
floating  kidney,  a  condition  which  should  be  treated  with  a  proper 
bandage  during  the  puerperium  and  later  removed  by  nephropexy. 


CHAPTER    III. 
FIBROIDS    OF   THE   ABDOMINAL   WALL. 

Sometimes  fibroids  develop  in  the  abdominal  wall  after  childbirth 
and  in  consequence  of  it.  The  development  begins  in  the  latter  part 
of  the  puerperium  or  still  later.  Probably  tears  in  the  connective 
tissue  or  muscle  substance,  or,  perhaps,  the  mere  process  of  involu- 
tion and  regeneration,  furnishes  the  impetus  to  the  formation  of  this 
benign  growth,  which  is  composed  of  elements  kindred  to  the  tissue 
in  which  the  tumor  originates. 

There  is  only  one  treatment  applicable  to  these  tumors, —  their 
operative  removal, — which  sometimes  can  be  accomplished  without 
opening  the  peritoneal  cavity.  In  other  cases  it  is  necessary  to  excise 
a  portion  of  peritoneum  together  with  the  tumor. 


CHAPTERIV. 

DISEASES    OF   THE   BREASTS. ^ 

Anomalous  Milk  Secretion. — In  rare  cases  there  is  no  secretion 
of  milk,  a  condition  called  agalactia.  In  other  rare  cases  the  secretion 
is  so  abundant  that  the  loss  of  substance  affects  the  health  of  the 
puerpera.  This  is  called  polygalactia.  Another  and  not  uncommon 
abnormality  is  galacton-hoea.     In  women  thus  affected  the  milk  flows 

^  Garrigues,  Diseases  of  Women,  third  ed.,  pp.  480-485. 

^  Garrigues,  "Inflammation  of  the  Breasts  and  Allied  Diseases  connected  with 
Childbirth,"  American  System  of  Obstetrics,  edited  by  Hirst,  Philadelphia,  1889, 
Lea  Brothers,  vol.  ii.  pp.  379-400. 


DISEASES    OF   THE   BREASTS.  759 

out  all  the  time,  even  when  the  child  does  not  suckle.  Often  this  is 
combined  with  polygalactia,  but  it  is  also  found  independently.  It  is 
bad  both  for  mother  and  child.  The  mother  has  the  discomfort  of 
having  her  clothes  wet  all  the  time.  She  is  apt  to  catch  cold.  She 
becomes  anaemic  and  weak,  and  complains  of  headache  and  backache. 
She  may  even  become  blind  or  insane.  The  great  loss  of  substance 
predisposes  her  to  tuberculosis.  Sometimes  severe  uterine  hemor- 
rhages occur  and  aggravate  the  anaemia. 

Too  protracted  lactation  or  lactation  by  a  woman  who  has  only 
little  milk  or  who  is  weak  and  ansemic  from  other  causes  has  a  similar 
effect. 

Galactorrhoea  may  sometimes  be  limited  by  compression  of  the 
breasts.  Potassium  iodide  given  internally  may  also  diminish  hyper- 
secretion. Sometimes  a  diversion  to  the  uterus  checks  the  flow  from 
the  breasts.  For  this  purpose  the  vaginal  portion  may  be  scarified,  or 
leeches  may  be  applied  to  it,  or  an  intra-uterine  electrode  may  be  con- 
nected with  the  negative  pole  of  a  galvanic  battery.^  If  nothing  avails, 
and  the  mother's  constitution  suffers  under  the  loss  of  milk,  lactation 
must  be  discontinued.  The  same  is,  of  course,  the  remedy  for  the 
consequences  of  protracted  lactation,  to  which  the  women  of  the 
lower  class  are  prone  in  order  to  avoid  a  new  pregnancy,  and  of  lacta- 
tion in  sickly  women.  Besides  thus  removing  the  drain  on  the  mother, 
she  should  be  strengthened  by  a  nourishing  diet,  wine,  chalybeates, 
arsenic,  phosphorus,  strychnine,  and  red  bone  marrow. 

For  the  babe  galactorrhoea  is  in  so  far  a  serious  matter  as  all  its 
nourishment  may  flow  out,  wetting  the  mother's  clothes  and  bed, 
and  nothing  may  be  left  for  it.  In  such  a  case  recourse  must  be  had 
to  a  wet-nurse  or  artificial  nursing. 

Not  infrequently  the  milk  becomes  deteriorated  and  unfit  to  nour- 
ish the  child  long  before  the  regular  period  of  weaning  arrives.  The 
milk  becomes  thin,  often  of  a  greenish  color,  and  under  the  micro- 
scope shows  by  far  not  so  closely  packed  fat-globules  as  does  healthy 
milk  (Fig.  237,  p.  233).  They  are  also  uneven  in  size  and  distribution 
(Figs.  497,  498). 

In  the  higher  classes  we  find  quite  frequently  that  the  women  can 
nurse  their  children  for  only  a  few  months.  When  the  milk  supply  is 
deficient,  but  the  milk  otherwise  is  good  and  the  mother  well,  she  may 
continue  to  give  her  child  what  she  has  and  supplement  it  with  some 
artificial  food.  In  such  a  case  it  is  advisable  to  let  her  nurse  the  child 
three  or  four  times  in  the  daytime  and  rest  at  night. 

The  milk  secretion  diminishes  if  the  mother  has  diarrhoea  or  fever, 
and  may  temporarily  stop  under  the  influence  of  emotions. 

We  may  try  to  increase  the  milk  supply  by  giving  the  patient  much 

^  Garrigues,  Diseases  of  Women,  third  ed. ,  p.  249. 


760 


ABNORMAL   PUERPERY. 


fluid  food.  The  author  is  in  the  habit  of  ordering  a  cup  of  milk,  tea, 
coffee,  chocolate,  cocoa,  chicken  broth,  clam  broth,  beef  tea,  oatmeal 
or  farina  gruel  to  be  given  every  two  hours. 

Wet-nurses  should  be  kept  on  the  diet  they  are  accustomed  to,  as 
a  sudden  change  is  apt  to  diminish  the  production  of  milk.  Beer 
undoubtedly  contributes  to  the  secretion,  and  is  much  relished  by 
nursing  women,  but  sometimes  causes  diarrhoea  in  the  child. 

There  is  a  proprietary  medicine  called  nutrolactis,  which  is  claimed 
to  increase  the  flow  of  milk,  but  some  patients  complain  that  it  nau- 


FiG.  497. 


Fig.  498. 


Milk  of  ansemic  woman.     (Louis  Fischer.; 


Milk  of  woman  fifteen  months  after  childbirth. 
( Louis  Fischer. ) 


seates  them.     If  the  lack  of  milk  is  due  to  atrophy  of  the  mammary 
glands,  there  is  no  help  for  it. 

Three  or  four  days  after  delivery,  in  pluriparae  usually  a  day  earlier, 
the  breasts  swell,  become  hard,  red,  and  painful.  There  is  a  more 
abundant  secretion  of  milk  than  the  child  can  digest,  or  sometimes 
the  milk  does  not  flow  easily  through  the  nipple,  or  the  child  has  not 
yet  learned  how  to  draw  it  out.  Under  these  circumstances  there  is 
an  accumulation  of  milk  in  the  mother's  breast  called  galactostash. 
There  is  often  a  slight,  rise  in  temperature,  known  as  milk  fever,  but 
it  does  not  rise  beyond  100.5°  F.,  and,  as  a  rule,  disappears  within 
twenty-four  hours.  A  higher  temperature  is  always  pathological  and 
requires  investigation. 

The  above-described  waist  (p.  239)  gives  the  woman  great  comfort. 

As  a  rule,  women  do  not  menstruate  during  lactation.  If  they  do, 
the  child  mostly  becomes  a  little  fretful  during  the  period,  but  other- 
wise sustains  no  harm,  and  the  mother  may  continue  to  nurse.  If 
menstruation  sets  in  and  then  stops  again,  it  is  usually  the  effect 
of  a  new  pregnancy.  As  soon  as  this  is  diagnosticated,  the  child 
should  be  weaned,  both  in  its  own  interest  and  in  the  mother's. 
The  milk  becomes  less  nourishing,  and  the  drain  on  the  mother  in 
nourishing  two  children,  one  with  her  milk  and  one  with  her  blood, 
is  injurious. 


DISEASES    OF   THE    BREASTS.  761 

§  2.  Sore  Nipples. — During  lactation  the  nipples  very  frequently 
become  diseased.  We  must  distinguish  superficial  excoriations,  which 
occupy  more  or  less  of  the  tip,  Q.nd  Jissu7'es,  which  are  deeper  linear 
ulcers.  Near  the  tip  they  are  longitudinal  and  more  or  less  radial, 
but  near  the  base  they  are  transverse,  and  may  become  so  extended 
that  the  nipple  adheres  to  the  breast  by  the  milk-ducts  only,  or  even 
is  completely  torn  off. 

The  excoriation  often  turns  into  a  plain  granulating  ulcer,  but  if  a 
wet-nurse  nurses  a  syphilitic  child  a  chcmcre  may  form  on  the  nipple. 
This  organ  may  also  be  the  seat  of  eczema. 

Etiology. — Predisposing  causes  of  sore  nipples  are  a  thin  epithe- 
lium and  short  nipples.  If  the  nipples  are  not  kept  clean  during 
pregnancy,  drops  of  milk  trickling  out  from  the  lactiferous  ducts  form 
together  with  old  epidermal  cells  a  scab,  under  which  the  epidermis 
atrophies  and  becomes  excessively  vulnerable.  Stiff  corsets  that 
press  on  the  nipples  have  a  similar  effect,  and  interfere  with  their 
normal  growth,  by  which  nature  prepares  them  for  the  function  they 
are  destined  to  perform.  When  the  nipples  are  too  short  the  child  is 
obliged  to  pull  with  much  greater  force  in  order  to  obtain  the  nour- 
ishment to  which  it  is  entitled,  and  consequently  the  nipple  is  more 
apt  to  suffer.  To  the  predisposing  causes  may  also  be  reckoned  that 
the  epithelium,  being  bathed  in  milk  during  the  act  of  suckhng,  be- 
comes macerated  and  loses  its  power  of  resistance. 

The  direct  cause  is  the  mechanical  injury  sustained  by  the  licking 
and  suction  of  the  child,  which  tears  the  epithelium. 

The  cause  of  the  fissures  is  to  be  sought  in  the  normal  folds  found 
on  the  top  and  at  the  base  of  the  nipple. 

Suppurating  nipples  abound  in  staphylococci  and  among  them  the 
pus-producing  staphylococcus  pyogenes  aureus  and  albus.  The  strepto- 
coccus pyogenes  is  much  rarer.  In  the  beginning  there  is  also  didium 
lactis,  which  is  said  to  be  identical  with  oidium  albicans,  the  fungus 
which  causes  the  sprue  in  the  mouth  of  suckhngs.  Some  think  the 
sprue  precedes  and  causes  the  sore  nipples  ;  but  since  these  are  much 
more  common  than  sprue,  the  converse  is  more  likely  to  be  the  re- 
lation between  cause  and  effect,  the  sprue  being  due  to  the  oidium 
sucked  in  from  the  nipple. 

Eczema  is  chiefly  due  to  lack  of  cleanliness,  but  I  have  also  seen  it 
in  women  who  were  particular  about  their  person. 

Excoriations,  and,  still  more,  fissures,  cause  a  pain  that  may  take 
such  proportions  that  lactation  becomes  a  torture.  The  patient  may 
lose  her  appetite  and  become  melancholy  and  nervous.  Her  pain 
may  be  such  that  she  cries  out  when  the  child  pulls,  and  that  the 
interval  is  filled  with  dread  of  the  next  application  of  the  child  to  her 
wounded  breast. 


762  ABNORMAL    PUERPERY. 

A  simple  excoriation  does  not  give  rise  to  fever,  but  ulcers,  espe- 
cially fissures,  may  cause  a  temperature  of  104°  F.  The  flat  excoria- 
tions heal  in  shorter  time,  but,  since  new  ones  may  form,  the  whole 
process  often  takes  several  weeks.  The  fissures  are  still  more  slow 
to  heal.  Sore  nipples  may  lead  to  mastitis,  and  contain,  therefore, 
apart  from  their  painfulness,  an  element  of  danger.  Consequently  we 
should  try  to  prevent  or  cure  them. 

Treatment. — Preventive  treatment  should  begin  during  pregnancy. 
The  nipples  should  be  kept  clean  with  soap  and  water.  Furthermore, 
they  should,  during  the  last  two  or  three  months,  be  washed  daily  with 
some  spirituous  or  astringent  fluid,  such  as  brandy  or  whiskey,  alco- 
hol mixed  with  equal  parts  of  water,  cologne,  or  glycerite  of  tannin. 

If  there  are  scabs  on  the  nipples,  they  ought  to  be  softened  and 
removed.  A  good  remedy  for  this  purpose  is  lead-water  mixed  with 
equal  parts  of  thin  oatmeal  gruel.  Pledgets  of  absorbent  cotton  or 
pieces  of  absorbent  lint  are  soaked  with  this  fluid,  applied  to  the  nip- 
ple, and  covered  with  gutta-percha  tissue. 

Short  nipples  may  be  elongated  by  cautiously  pulling  on  them  for 
a  minute  or  two  every  day.  In  a  person  suff"ering  from  habitual 
abortion  this  should,  however,  not  be  done,  as,  on  account  of  the 
connection  between  the  breasts  and  the  uterus,  pulling  on  the  nipples 
provokes  uterine  contractions. 

During  the  latter  half  of  pregnancy  women  ought  to  abandon  their 
cherished  corset  and  wear  only  a  soft  waist  that  cannot  exercise  any 
injurious  pressure  on  the  nipples. 

For  the  curative  treatment  of  sore  nipples  we  have  about  as  long 
a  hst  of  remedies  as  for  seasickness,  a  bad  sign,  which  shows  that 
none  have  proved  to  be  of  marked  efficacy.  My  routine  treatment 
in  Maternity  Hospital  was  to  dust  the  sore  with  dry  tannin  and  to 
cover  it  with  a  small  circular  piece  of  lint  soaked  in  glycerin  or 
smeared  with  vaseline.  Outside  of  this  came  a  piece  of  gutta-percha 
tissue,  and  the  whole  was  kept  in  place  with  the  above-described 
waist.  Very  often  the  sore  heals  under  this  treatment,  without  inter- 
rupting the  nursing ;  and,  since  we  were  absolutely  free  from  mam- 
mary abscesses,  I  think  it  has  considerable  value. 

If  the  sore  is  large  or  deep  and  the  pain  great,  it  is  necessary  to 
discontinue  nursing  for  a  shorter  or  longer  period, — in  bad  cases  as 
much  as  four  days, — and  relieve  the  breasts  by  milking  them  with  the 
fingers,  much  in  the  fashion  the  milkmaid  milks  her  cow.  In  so  doing 
the  nurse  carefully  avoids  touching  the  sore  places.  This  is  prefer- 
able to  the  kneading  of  the  breast  and  to  the  use  of  the  breast-pump. 
The  latter  tears  the  sores  open  and  exercises  a  painful  and  injurious 
pressure  in  its  circumference,  and  both  procedures  rather  promote 
than  prevent  mastitis. 


DISEASES   OF   THE    BREASTS. 


763 


Fig.  500. 


A  soft-rubber  shield  (Fig.  499)  placed  over  the  areola  during  nurs- 
ing in  many  cases  offers  great  comfort.  It  is  held  with  the  fingers 
against  the  breast,  and  the  milk  is  sucked  out  by  the  baby  through 
fine  openings  ;  but  sometimes  no  amount  of 
coaxing  can  prevail  upon  the  child  to  pull 
on  the  short  nipple.  Then  another  nipple- 
shield  (Fig.  500)  may  be  tried,  which  con- 
sists of  a  glass  cup  covering  the  nipple  and 
a  large  soft-rubber  nipple  which  fits  well  in 

Fig.  499. 


Nipjjle-bhield. 


Nipple-shield. 


the  child's  mouth.     All  such  shields  should  be  washed  scrupulously 
and,  when  not  in  use,  kept  in  a  saturated  solution  of  boric  acid. 

Led  by  the  marvellous  effect  chloral  hydrate  has  on  anal  fissures, 
I  tried  this  drug  also  on  sore  nipples  and  found  it  very  satisfactory. 
The  nipple  is  dressed  with  a  four  per  cent,  solution  on  absorbent 
lint.     Another  drug  that  has  been  useful  in  my  hands  is  orthoform  : 

R    Orthoformi,   51  (4  grammes)  ; 
Lanolini,   ^i  (30  grammes). — M. 
Sig. — For  external  use. 


For  the  dry  treatment  dermatol  may  be  used  instead  of  tannin. 
Ichthyol  may  take  the  place  of  orthoform  : 

B    Ichthyol.,   3i  (4  grammes)  ; 
Lanolini,   ^iss  (6  grammes)  ; 
Glycerini,  flgiss  (6  grammes)  ; 
01.  olivarum,   §iiss  (75  grammes). 

Carbolic  acid  in  3  per  cent,  solution  may  be  used  on  compresses. 
Nitrate  of  silver,  5  per  cent.,  may  be  painted  on  the  nipple  with  a 
camel's-hair  brush  once  a  day.  White  vaseline  in  tubes  is  in  some 
cases  as  good  as  anything.  Small  rubber  ice-bags  (a  condom  or 
"two-finger  protector")  relieve  pain  and  combat  inflammation. 

Whatever  is  done,  the  nipple  and  the  child's  mouth  should  be 
washed  out  with  sterilized  water  before  and  after  each  nursing. 


764  ABNORMAL    PUERPERY. 

If  granulating  ulcers  resist  the  milder  means  enumerated  above, 
they  should  be  touched  with  lunar  caustic.  If  the  sores  will  not 
heal  and  the  patient's  general  health  suffers,  it  may  become  neces- 
sary for  her  to  give  up  nursing  altogether,  when  the  nipples  heal  in 
a  short  time. 

Syphilitic  ulcers  call  for  the  local  and  general  treatment  usual 
in  that  disease.  If  the  ulcer  is  caused  by  the  bite  and  sucking  of 
the  child,  nothing  is  gained  by  weaning  it ;  but  if  the  chancre  is 
produced  in  any  other  way,  the  child  should  at  once  be  removed 
from  the  nurse  and  undergo  specific  treatment.  If  the  child  nurses 
its  own  mother  and  a  syphilitic  ulcer  appears  on  her  nipple,  the  child 
need  not  be  weaned,  for  the  milk  cannot  add  to  the  harm  done  by 
the  blood  from  which  the  child's  body  has  been  built  up,  unless  the 
syphilis  has  been  acquired  after  the  birth  of  the  child.  Then  it  ought 
to  be  weaned  at  once. 

Eczema  is  treated  with  the  above-mentioned  mixture  of  lead- 
water  and  oatmeal  gruel,  followed  by  an  ointment : 

R    Plumbi  oxidi,  ^ii  (8  grammes)  ; 
01.  olivarum,  gvi  (24  grammes)  ; 
Aquae,   ^i  (30  grammes). — M. 
Boil  to  the  consistency  of  thick  cream. 

Still  later  the  nipple  is  dusted  with — 

R    Zinci  oxidi,  ,^i  (4  grammes)  ; 
Amyli,  gi  (30  grammes). — M. 

If  there  is  much  itching,  camphor,  si  (4  grammes),  may  be  added, 
or,  if  the  skin  is  healed,  a  lotion  with  carbohc  acid  may  be  substituted 
(p.  744). 

§  3.  Deep  Inflammation  of  the  Nipples. — In  rare  cases  the  in- 
terior of  the  nipple  becomes  inflamed,  the  seat  of  the  inflamma- 
tion being  either  the  lactiferous  ducts  or  the  interstitial  connective 
tissue.     Both  may  end  in  resolution  or  in  suppuration. 

In  the  inflammation  of  the  ducts  the  nipple  is  moderately  swol- 
len, and  small  abscesses  may  form  in  the  interior,  which  contain  a 
milky  pus.  This  sometimes  dribbles  from  the  apex,  and,  as  it  is 
swallowed  by  the  child,  the  affection  is  serious. 

In  the  interstitial  form  there  are  more  swelhng  and  greater 
pain.  The  pus  is  thick  like  cream,  but,  since  it  is  not  likely  to  be 
aspirated  by  the  child,  this  variety  is  less  dangerous.  It  forms  a  glob- 
ular tumor,  which  breaks  through  or  is  opened  on  the  side  of  the 
nipple  and  soon  closes.  In  both  kinds  the  pain  may  become  so  great 
that  lactation  has  to  be  given  up. 


DISEASES   OF   THE    BREASTS.  765 

Treatment. — Lactation  must  be  discontinued.  Resolution  may  for 
a  few  days  be  furthered  by  the  application  of  a  small  ice-bag ;  but  if 
suppuration  is  inevitable  it  is  hastened  by  the  application  of  a  Avarm 
poultice.  In  the  inflammation  of  the  ducts  nothing  more  can  be 
done  ;  in  that  of  the  connective  tissue  the  abscess  should  be  opened 
with  the  knife  as  soon  as  it  is  formed,  and  dressed  with  gauze  wrung 
out  of  creohn,  lysol,  or  carbolic  acid  (1  per  cent.)  or  impregnated 
with  iodoform. 

§  4.  Eczema  of  the  Areola. — The  areola,  as  well  as  the  nipple, 
may  become  the  seat  of  eczema,  characterized  by  itching  and  the 
formation  of  vesicles,  pustules,  and  small  yellow  or  brown  scabs.  This 
condition  is  independent  of  eczema  in  the  rest  of  the  body.  It  may 
resist  treatment  for  some  time.  The  treatment  is  the  same  as  that 
described  for  eczematous  nipples. 

§  5.  Cellulitis  and  Adenitis  of  the  Areola. — The  connective  tissue 
underlying  the  areola  and  the  glands  protruding  on  its  surface  may 
become  inflamed  and  form  small  abscesses.  This  is  due  chiefly  to  the 
child's  attempts  to  suck  from  too  short  nipples  or  is  a  sequel  of  sore 
nipples.  The  skin  becomes  red  and  there  are  pain  and  fever.  Small 
sensitive  lumps  are  developed,  and,  if  suppuration  sets  in,  a  yellow 
spot  appears  in  the  centre  of  the  nodules.  One  or  more  openings 
perforate  the  skin  and  form  a  deep  ulcer,  followed  by  an  irregular 
scar  or  a  hard  nodule,  slow  to  disappear. 

Treatment. — The  prophylaxis  consists  in  attention  to  the  nipples. 
Short  nipples  should  be  pulled  out  with  the  fingers  or  a  breast-pump 
each  time  before  the  child  nurses.  Sore  nipples  should  be  treated 
at  their  first  appearance  as  described  above.  When  abscesses  form, 
they  should  be  opened  at  once  and  dressed  antiseptically,  when  they 
promptly  heal. 

§  6.  Erysipelas  of  the  Breasts. — Before  the  introduction  of  the 
antiseptic  treatment  in  Maternity  Hospital,  erysipelas  of  the  breasts  was 
not  a  rare  occurrence  ;  and  I  have  even  seen  it  spread  over  the  whole 
body  and  end  fatally.  It  starts  from  sore  nipples  or  a  mammary 
abscess  and  is  due  to  a  specific  microbe,  streptococcus  erysipclatis. 

The  skin  becomes  dark  red  and  hot,  swollen,  tender  on  pressure, 
and  is  separated  from  the  healthy  portion  by  a  distinct  line  of  de- 
marcation. The  pulse  becomes  rapid,  temperature  runs  high,  there 
are  often  digestive  disturbances,  and  the  patient  complains  of  thirst. 
In  general  the  disease  ends  in  desquamation,  but  it  may  also  become 
bullous,  phlegmonous,  or  gangrenous. 

Treatment. — Nursing  with  the  affected  breast,  or  in  bad  cases  with 
both,  must  be  interrupted,  at  least  temporarily.  Tinctura  ferri  chlo- 
ridi  ("Lxx — 120  centigrammes)  should  be  given  every  two  hours. 
The  affected  part  and  an  inch  all  around  it  should  be  painted  with 


766  ABNORMAL   PUERPERY. 

undiluted  creolin  hvice  a  day.  Beta-naphtol  mixed  with  vaseline  (gr. 
XXV  to  si — 160  centigrammes  to  30  grammes)  rubbed  into  the  skin 
is  also  good.  Liquor  gutta-perchae  forms  an  air-tight  pellicle,  which 
seems  to  kill  the  microbe.  Compresses  soaked  in  carbolized  ice-water 
(from  ]  to  2  per  cent.)  and  changed  frequently  afford  a  pleasant  sen- 
sation of  refrigeration.  Bullae  should  be  opened  and  dusted  with  iodo- 
form or  dressed  with  iodoform  vaseline  (si  to  gi — 4  to  30  grammes). 
In  the  gangrenous  form  dead  tissue  should  be  cut  away  with  knife  or 
scissors,  and  the  wound  dressed  with  camphor  emulsion  (p.  745). 

§  7.  Lymphang-eitis  of  the  Breasts. — The  breasts  have  two  layers 
of  lymphatics,  a  superficial  and  a  deep.  The  superficial,  or  subcu- 
taneous, consists  of  a  delicate  meshwork  of  vessels  limited  to  the 
areola  and  the  nipple.  The  deep,  or  glandular,  layer  surrounds 
the  lobes  and  lobules  of  the  mammary  gland.  Trunks  start  from 
the  posterior  surface  and  from  the  interior  of  the  gland  and  go  to 
the  areola,  where  they  form  a  plexus  of  very  large  vessels.  From 
the  areola  two  or  three  voluminous  trunks  carry  the  lymph  to  the 
axillary  glands. 

These  latter  trunks  in  rare  instances  become  inflamed  and  are 
visible  as  pink  streaks  extending  from  the  nipple  to  the  axilla.  The 
patient  becomes  feverish  and  complains  of  pain.  As  a  rule,  the 
disease  ends  in  resolution  and  lasts  only  a  few  days.  But  it  may 
end  also  in  suppuration,  forming  small  superficial  abscesses. 

This  inflammation  is  due  to  the  infection  of  sore  nipples. 

Treatment. — The  breasts  should  be  lifted  and  evenly  compressed 
with  the  above-described  waist  (p.  236).  Outside  is  placed  an  ice- 
bag,  which  is  held  in  place  by  a  piece  of  muslin  pinned  around  the 
chest,  and  in  which  a  hole  is  made  for  the  metal  cap  of  the  bag. 
Nursing  from  the  affected  breast  should  be  interrupted,  but  may  be 
resumed  when  the  disease  has  run  its  course.  Abscesses  should  be 
laid  open  and  dressed  antiseptically. 

It  is  not  unlikely  that  there  may  be  a  similar  affection  in  the 
depth  of  the  gland,  but  that  becomes  merged  in  the  inflammation 
of  the  connective  tissue,  which  presently  will  be  considered. 

§  8.  Mastitis. — Mastitis,  or  inflammation  of  the  breast,  is  some- 
times designated  by  the  Scotch  word  a  iceed. 

According  to  its  seat,  above,  in,  or  below  the  mammary  gland, 
three  varieties  are  distinguished — the  subcutaneous,  the  glandular^ 
and  the  suhglandular,  of  which  the  glandular  is  by  far  the  most 
frequent. 

The  subcutaneous  variety  is  situated  in  the  connective  tissue  be- 
tween the  skin  and  the  gland,  and  may,  like  cellulitis  in  other  parts 
of  the  body,  be  circumscribed  or  diffuse.  In  the  circumscribed  form  one 
or  more  points  of  the  skin  become  red  and  swollen,  and  fluctuation 


DISEASES    OF   THE  BREASTS. 


767 


is  soon  established.  The  diffuse  form  usually  begins  as  erysipelas.  It 
may  break  through  the  skin  in  many  points.  Long  shreds  of  con- 
nective tissue  may  be  pulled  out,  and  finally  a  large  ulcer  forms,  at 
the  bottom  of  which  lies  the  denuded  gland.  This  is  a  dangerous 
but  fortunately  rare  disease. 

In  the  glandular  variety  the  seat  of  the  inflammation  is  deeper  and 
surrounds  the  acini  (Fig.  501).     During  lactation  the  cuboidal  epithe- 


FiG.  501. 


Puerperal  mastitis  forming  abscess.     (Billroth.)    a,  group  of  acini  melted  to  pus. 


lium  of  the  acini  (Fig.  236,  p.  232)  melts,  forms  fat-globules,  and  takes 
no  part  in  the  inflammation,  which  begins  in  the  interacinous  connec- 
tive tissue,  just  outside  of  the  acini ;  but  when  an  abscess  forms  it 
mav  break  into  the  acini  and  the  finer  milk-ducts. 


768  ABNORMAL    PUERPERY. 

In  the  suhglandular  variety  the  inflammation  takes  place  in  the 
loose  connective  tissue  between  the  gland  and  the  thorax.  Sometimes 
an  abscess  here  communicates  with  a  subcutaneous  one  through  a 
canal  in  the  mammary  substance — collar-button  abscess. 

The  right  breast  is  more  often  aff'ected  with  mastitis  than  the  left. 
Sometimes  both  become  inflamed. 

Etiology. — Mastitis  is  nearly  exclusively  found  in  women  who 
nurse.  A  woman  who  does  not  make  any  attempt  at  nursing  is 
almost  safe  from  the  attacks  of  this  disease.  This  goes  far  to  show 
that  nursing  has  something  to  do  with  the  appearance  of  the  disease. 
On  the  other  hand,  if  a  woman  begins  to  nurse  and  gives  it  up  after 
the  milk  secretion  is  well  established,  she  is  more  apt  to  get  a  mastitis 
than  if  she  had  not  begun.  It  has  been  observed  during  pregnancy, 
and  could  then  be  explained  by  lack  of  cleanliness. 

The  inflammation  is  ascribed  to  microbes, — staphylococci  and 
streptococci  or  schizomycetes  ;  but  even  the  first  drops  of  milk  that 
come  from  the  breasts  of  a  woman  in  perfect  health,  as  a  rule,  con- 
tain these  microbes,  especially  the  staphylococcus  aureus.  It  is  there- 
fore necessary  to  look  for  other  causes  besides  the  microbes,  which 
undoubtedly  are  the  direct  cause  of  the  suppuration. 

The  laity  usually  ascribes  the  disease  to  refrigeration ;  but,  if  even 
occasionally  exposure  may  .  aid  to  its  development,  the  fact  that  it 
is  found  independently  of  season  and  climate  shows  that  this  cause 
can  have  only  little  influence  on  its  production. 

Sore  nipples,  on  the  other  hand,  have  undoubtedly  much  to  do 
with  its  appearance.  At  least  an  abrasion  and  often  deep  fissures  are 
found  in  nearly  every  case ;  or  if,  exceptionally,  they  are  not,  they 
may  have  been  overlooked  and  healed  before  the  breast  becomes  in- 
flamed. This  supposition  fits  well  with  the  seat  of  the  inflammation, 
which,  as  we  have  seen,  is  in  the  connective  tissue.  In  the  denuded 
part  of  the  nipple  the  spaces  between  the  threads  of  the  connective 
tissue  lie  open,  and  the  microbes  can  easily  find  their  way  through  the 
meshes  to  the  deeper  parts.  They  may  also  go  through  the  lactiferous 
ducts,  although  they  then  must  mount  against  the  current. 

Stagnation  of  milk  is  another,  and,  in  my  opinion,  most  potent 
factor  in  the  production  of  the  inflammation.  This  is  borne  out  by 
the  observation  that  it  often  is  preceded  by  a  general  or  partial  swell- 
ing of  the  breast,  which  is  relieved  by  emptying  the  ducts.  This 
theory  is  also  corroborated  by  the  frequency  of  mammary  abscess  in 
women  who  suddenly  stop  nursing,  although  they  have  plenty  of 
milk.  The  correctness  of  this  view  is,  in  my  opinion,  most  of  all 
proved  by  my  experience  in  Maternity  Hospital.  Before  the  intro- 
duction of  the  new  treatment  of  the  breasts,  I  had  constantly  cases  of 
mammary  abscess.    But  later  I  had  only  a  single  case  during  eight  or 


DISEASES   OF   THE   BREASTS.  769 

nine  years,  and  that  was  in  a  scrofulous  little  person  upon  whom  I 
performed  Csesarean  section,  and  who  on  her  neck  had  large  scars 
from  suppurating  glands  in  childhood.  This  wonderful  immunity  was 
obtained  by  dressing  the  sore  nipples  with  tannin,  compressing  the 
breasts  evenly  with  our  waist,  and  keeping  them  empty  either  by 
letting  the  babies  suck  or  by  milking  them  with  the  fingers. 

I  am  still  more  inclined  to  lay  the  greatest  stress  on  the  galac- 
tostasis  as  a  factor  in  the  production  of  mastitis  when  I  compare 
the  results  in  my  hospital  service  with  those  of  my  private  practice. 
Although  the  treatment  ordered  is  the  same,  I  do  not  entirely  escape 
mammary  abscesses  in  private  practice,  which  I  think  is  due  to  the 
inferior  way  in  which  private  nurses,  be  they  trained  or  untrained, 
carry  out  the  treatment  of  the  breasts.  The  less  perfect  depletion  of 
the  milk-ducts  is,  in  my  opinion,  the  only  reason  why  the  results  are 
not  so  uniformly  satisfactory  in  private  practice  as  in  the  hospital. 
This  view  does  in  no  way  interfere  with  the  theory  of  the  microbes 
being  the  true  cause  of  the  mastitis.  These  enter  through  the  aper- 
tures of  the  lactiferous  ducts  or  are  already  in  their  interior.  When 
the  milk  stagnates,  they  decompose  it  and  cause  inflammation  of  the 
surrounding  glandular  tissue.  But  the  question  is  of  the  greatest 
practical  importance,  because  the  treatment  becomes  diametrically 
opposite. 

The  inflammation  may  also  have  its  cause  in  sprue.  When  a 
child  thus  affected  nurses,  it  may  deposit  the  fungi  on  the  sore  nipple 
or  in  the  openings  of  the  lactiferous  ducts,  whence  they  find  their 
way  to  the  deeper  parts  of  the  breast. 

Pus-producing  microbes  may,  of  course,  also  easily  be  brought 
from  the  genitals  of  the  mother  or  from  the  umbilicus  of  the  child, 
from  the  nurse's  or  the  patient's  own  fingers,  or  from  clothing,  etc. 

Primiparse  are  much  more  apt  to  be  affected,  which  probably  is 
due  to  the  fineness  of  the  epithelium  of  the  nipple.  After  having 
passed  through  two  confinements  and  nursed  her  child  a  woman 
rarely  gets  an  inflamed  breast. 

Symptoms  and  Course. — The  inflammation  begins  generally  in  the 
second  week  of  the  puerperium,  but  may  occur  any  time  as  long  as 
the  woman  nurses.  It  is  even  as  common  in  the  tenth  as  in  the  first 
month,  which  is  one  sign  among  others  that  lactation  should  not  be 
unduly  protracted.  It  is  heralded  by  a  rigor,  or  chilly  sensations,  and 
temperature  runs  up  to  from  102°  to  104°  F.  or  still  higher.  The 
pulse  is  accelerated.  The  patient  has  no  appetite,  but  complains  of 
thirst,  weakness,  and  pain  in  the  breast.  The  breast  becomes  swollen, 
hot,  and  red,  but  in  these  respects  there  is  some  difference  between 
the  different  varieties. 

1.  In  circumsci'ibed  subcutaneous  mastitis  one  or  more  points  soon 

49 


770  ABNORMAL    PUERPERY. 

become  red  and  prominent,  and  fluctuation  becomes  distinct  at  an 
early  date.  In  order  to  feel  it,  it  is  best  to  immobilize  the  breast 
against  the  thorax  with  the  hollow  of  one  hand,  and  examine  the 
swelling  with  the  other  hand  and  some  fingers  of  the  first,  or  to  com- 
press the  breast  with  one  hand  from  side  to  side  and  press  with  the 
index-finger  of  the  other  on  the  most  prominent  point. 

2.  Glandular  3Iastitis. — ^^Ve  have  seen  (p.  94)  how  during  preg- 
nancy the  mammary  gland  undergoes  an  enormous  development.  We 
can  readily  imagine  how  a  mammary  abscess  may  begin  in  different 
minute  foci,  which  gradually  become  confluent  and  form  one  cavity. 
In  most  cases  the  mflammation  begins  just  outside  of  the  acini,  but  a 
glandular  abscess  may  also  begin  under  the  skin  or  behind  the  gland 
and  secondarily  implicate  the  gland.  One  or  more  hard,  tender, 
globular  nodules  or  swollen,  sensitive  lactiferous  ducts  are  felt.  The 
skin  is  at  first  normal,  but  later  it  becomes  red  and  hot,  and  some- 
times oedematous.  If  suppuration  supervenes,  the  hard  nodule  softens 
in  the  centre,  and  gradually  the  softness  extends  to  the  periphery.  It 
may  take  from  one  to  three  weeks  before  the  abscess  is  completed. 
Often  one  develops  after  the  other,  and  the  inflammation  may  extend 
to  the  subcutaneous  or  subglandular  connective  tissue.  In  such  cases 
the  process  may  take  many  months. 

As  a  rule,  the  inflammation,  if  properly  treated,  ends  in  resolu- 
tion in  a  few  days,  but  if  the  initial  fever  lasts  over  four  days  the 
inflammation  nearly  ahvays  ends  in  suppuration.  (Edema  is  also  a 
sign  of  a  deep-seated  suppuration.  Sometimes  the  pus  is  ichorous, 
offensive,  and  contains  gas. 

The  prognosis  is,  as  a  rule,  good.  Mastitis  rarely  leads  to  general 
sepsis,  but  in  protracted  cases  the  constitution  suffers  and  the  victim 
may  become  tuberculous.  Exceptionally,  a  blood-vessel  has  been 
eroded  and  given  rise  to  fatal  hemorrhage.  A  large  part  of  the  gland 
may  be  destroyed,  fistula  may  remain,  and  old  scars  may  predispose 
to  the  formation  of  another  abscess  in  subsequent  pregnancies. 

3.  Subglandular  onastitis,  like  the  subcutaneous,  develops  rapidly, 
and  it  ends  almost  constantly  in  suppuration.  In  from  two  to  five 
days  it  is  fully  developed.  The  skin  in  this  variety  remains  pale  or 
is  only  slightly  reddened ;  there  are  no  nodules,  but  the  whole  breast 
is  lifted  up  and  gives  the  impression  as  if  resting  on  an  air-cushion. 
The  pain  is  deep-seated.  If  neglected,  this  variety  may  penetrate 
the  thorax  and  cause  pleurisy,  or  extend  down  to  the  abdomen  or  up 
to  the  axilla  and  the  neck.  It  may  even  corrode  bones  and  cartilages. 
Fluctuation  may  be  difficult  to  feel,  so  that  it  becomes  necessary  for 
diagnostic  purposes  to  make  an  exploratory  aspiration  with  a  hypo- 
dermic syringe. 

Treatment. — The  prophylaxis  is  directed  against  the  nipples  and  the 


DISEASES   OF   THE    BREASTS.  771 

breasts  themselves.  During  pregnancy  the  nipples  should  be  kept 
clean,  emolliated,  or  hardened,  and,  if  too  short,  cautiously  pulled  out 
(pp.  128,  762).  During  the  puerperium  they  should  be  constantly 
examined  and  the  slightest  excoriation  carefully  treated,  as  described 
above.  The  application  of  the  waist  (p.  239)  in  all  cases  from  the 
fourth  to  the  ninth  day  has  proved  of  immense  value.  If  the  child  is 
dead  or  the  mother  does  not  want  to  nurse  it,  the  breasts  should  be 
treated  as  described  on  p.  234. 

In  nursing  women  the  breasts  are  emptied  at  regular  intervals  by 
one  or,  if  there  is  a  superabundance  of  milk,  even  two  babies,  unless 
sore  nipples  necessitate  a  temporary  discontinuation  of  nursing,  when 
the  nurse  should  milk  the  breasts  out  as  stated  above. 

With  this  treatment  mammary  abscesses  practically  disappeared 
from  my  service  in  Maternity  Hospital,  and  even  the  earlier  stage  of 
mastitis  became  exceedingly  rare.  In  mild  cases,  which  probably 
are  due  to  congestion,  I  only  keep  the  breasts  empty  and  compressed. 
If  there  are  swelling,  redness,  pain,  and  fever,  an  ice-bag  is  applied, 
outside  of  the  binder,  over  the  seat  of  the  inflammation,  and  kept  in 
place  with  a  piece  of  muslin  pinned  around  the  chest.  A  saline 
aperient  is  administered,  and  five  grains  of  quinine  are  given  three  or 
four  times  a  day. 

A  question  of  the  greatest  practical  importance  is  as  to  whether 
or  not  the  patient  shall  nurse.  If  the  nipples  are  sore,  it  is  better  to 
suspend  lactation  for  a  few  days  and  empty  the  breasts  by  milking. 
If  the  nipples  are  healthy,  the  more  the  child  sucks  the  better  it  is. 
If,  however,  there  is  a  pus  focus  in  open  connection  with  a  lactiferous 
duct,  it  is  necessary,  in  order  to  prevent  the  child  from  swallowing 
the  abnormal  admixture  to  the  milk,  to  stop  nursing  from  the  affected 
breast.  When  the  abscess  is  healed  and  hardness  has  disappeared, 
lactation  may  be  resumed,  but  its  effect  ought  to  be  closely  watched, 
and  at  the  first  reappearance  of  pain,  tenderness,  or  swelling,  it  ought 
to  be  forbidden  at  once  and  for  good. 

If  suppuration  is  unavoidable,  it  is  better  to  hasten  it  by  means  of 
warm  flaxseed-meal  poultices.  When  fluctuation  or  aspiration  shows 
that  the  abscess  has  been  formed,  it  should  be  opened.  In  the  subcu- 
taneous and  the  subglandular  varieties  this  should  be  done  at  once. 
In  the  glandular  it  is  better,  if  the  abscess  is  deeply  situated,  to  let  it 
have  time  to  approach  the  surface. 

The  subcutaneous  abscess  is  generally  small,  and  one  moderately 
long  incision  with  a  bistoury  is  all  that  is  required.  On  account  of 
the  tension  of  the  skin,  the  opening  Avill  gape  less  and  make  a  less  un- 
sightly scar  if  it  is  made  in  the  direction  of  a  radius  from  the  nipple 
to  the  periphery  of  the  breast. 

If  the  abscess  is  situated  partly  under  the  areola  and  partly  out- 


772  ABNORMAL   PUERPERY. 

side  of  it,  the  incision  should  either  be  made  all  inside  or  all  outside 
of  the  line  of  demarcation  between  the  areola  and  the  common  skin. 
Otherwise  the  pigmentation  of  the  areola  is  apt  to  spread  along  the 
lips  of  the  wound  and  cause  a  permanent  irregularity  of  the  contour 
of  the  areola. 

The  subglandular  variety  is  opened  where  it  points,  which  usually 
is  outward  and  downward.  In  this  case  the  incision,  an  inch  or  more 
in  length,  should  be  made  parallel  to,  or,  if  feasible,  at  the  contour 
of  the  breast,  and,  if  no  counter-opening  is  deemed  necessary,  a  soft- 
rubber  drainage-tube  should  be  pushed  in  to  the  opposite  wall  of  the 
abscess  cavity,  and  a  safety-pin  fastened  in  the  proximal  end  of  the 
tube  in  order  to  prevent  it  from  being  drawn  into  the  interior.  A 
little  gauze  is  wound  around  the  pin,  so  as  to  avoid  pressure  on  the 
skin. 

The  glandular  variety  often  needs  two  or  three  openings  in  order 
to  have  good  drainage,  but  they  need  not  be  more  than  half  an  inch 
in  length.  When  the  first  is  made,  a  probe  is  pushed  through  and  the 
second  incision  is  made  against  its  point.  The  best  drain  is  a  bundle 
of  horse-hair  properly  cleaned  with  soap  and  water  and  bichloride  of 
mercury.  The  bundle  is  carried  through  from  one  opening  to  the 
other  with  a  long,  flat,  blunt  needle  with  a  large  eye,  and  tied  loosely 
over  the  breast.  Silkworm  gut  is  also  very  good.  Thin  soft-rubber 
tubes  may  also  be  used,  but  their  insertion,  if  it  is  done  without  an 
anaesthetic,  is  more  painful  than  that  of  the  other  substances.  The 
drains  should  remain  as  long  as  there  is  any  discharge.  If  there  is 
only  one  opening,  the  tube  should  be  shortened  gradually. 

The  operation  is,  of  course,  done  with  the  usual  aseptic  and  anti- 
septic precautions.  The  skin  is  disinfected,  the  instruments  are 
boiled  with  soda  solution,  the  abscess  cavity  is  irrigated  with  lysol  or 
creolin  (2  per  cent.),  and  finally  the  breast  is  covered  with  large  pads 
of  gauze  wrung  out  of  the  same  solution,  some  water-proof  material, 
such  as  oil-silk,  oil-muslin,  or  gutta-percha  tissue,  and  all  is  kept  in 
place  by  the  breast-binder,  which  is  sufficiently  tightened  to  keep  up 
a  moderate  pressure.  The  dressing  is  changed  once  a  day,  and  at 
the  same  time  the  drains  are  cleaned  by  irrigation.  Tonics,  especially 
chloride  of  iron  and  strychnine,  are  given.  By  this  treatment  even  a 
large  abscess  heals  in  eight  or  ten  days. 

Some  women  have,  however,  such  a  horror  of  the  knife  that  they 
object  to  its  use  on  their  breast.  In  the  subcutaneous  and  especially 
the  subglandular  variety,  the  doctor  should  insist,  and  tell  the  patient 
that  if  not  opened  the  abscess  may  cause  great  destruction  and  even 
lead  to  a  fatal  issue.  If  situated  in  the  gland  it  is  not  so  imperatively 
indicated  to  open  the  abscess.  Still  the  physician  should  inform  the 
patient  that  by  leaving  it  alone  her  pain  wifi  be  much  prolonged,  that 


DISEASES    OF   THE   BREASTS.  773 

a  larger  part  of  the  gland  will  be  destroyed,  that  the  suppuration  may 
involve  the  subglandular  and  subcutaneous  tissue,  and  that  the  scar 
will  be  much  more  unsightly.  The  pain  may  be  lessened  or  deadened 
by  the  spray  of  ethyl  chloride,  by  the  previous  subcutaneous  injection 
of  cocaine  in  the  track  of  the  incision,  or,  where  a  greater  interference 
is  expected,  even  by  general  anaesthesia. 

If  the  abscess  is  covered  by  much  glandular  tissue,  the  incision 
of  which  may  give  rise  to  considerable  hemorrhage,  especially  in  old 
neglected  cases,  it  is  best  only  to  cut  through  the  skin,  the  subcutane- 
ous fat,  and  the  fascia.  When  the  gland  is  reached,  a  pointed  director 
is  thrust  through  it  into  the  abscess  cavity,  a  pair  of  slender  forceps  is 
slid  in  on  it  and  forcibly  opened,  so  as  to  let  out  the  pus.  A  drainage- 
tube  is  then  inserted  between  the  branches  and  the  breast  treated 
as  just  described. 

If  hard  nodules  remain  after  the  abscess,  they  are  rubbed  and  cov- 
ered with  resolvent  ointments,  such  as  unguentum  hydrargyri,  potassii 
iodidi,  or  plumbi  iodidi.  If  the  child  is  weaned,  iodide  of  potassium 
may  be  given  internally  at  the  same  time.  The  help  of  the  galvanic 
current  may  also  be  invoked  to  scatter  the  swelling.  Fistulse  will  be 
considered  below. 

Cold  or  Chronic  Abscess  of  the  Breast. — Besides  the  acute 
suppuration  described  above,  a  chronic  or  so-called  cold  abscess  may 
form  in  the  breast  in  connection  with  lactation.  It  has  been  found  in 
otherwise  healthy  women,  without  scrofulous  or  tuberculous  ante- 
cedents. It  is  generally  of  the  subglandular  variety.  It  may  begin  as 
a  common  abscess  with  pain,  but  soon  this  subsides,  and  the  inflam- 
mation progresses  very  slowly,  during  a  period  of  from  three  weeks 
to  two  months.    In  other  cases  there  is  no  pain  at  all. 

Treatment. — As  soon  as  the  abscess  is  formed,  it  should  be  opened 
by  one  or  more  openings,  and  tincture  of  iodine  should  be  injected  or 
the  sore  dusted  with  iodoform.  Otherwise  the  abscess  is  treated  like 
the  acute  variety. 

§  9.  S-welling  and  Milk  Retention  in  Accessory  Mammary 
Glands. — Occasionally  I  have  seen  a  swelling  of  and  milk  retention  in 
an  accessory  mammary  gland  in  the  axilla.  Sometimes  both  sides 
were  affected  in  the  same  way.  In  the  axilla  is  found  a  painful  swell- 
ing, sensitive  to  the  touch,  covered  with  skin  of  normal  or  pink  color. 
Often  the  swelling  is  divided  into  two  parts  by  a  sulcus.  There  may 
be  distinct  fluctuation,  but  the  aspired  fluid  is  only  milk.  In  spite 
of  careful  palpation  I  have  not  been  able  to  find  any  connection  be- 
tween the  axillary  swelling  and  the  mammary  gland. 

These  swellings  should  be  covered  with  a  thick  layer  of  unguen- 
tum iodi,  when  they  disappear  in  a  few  days.  I  have  never  seen 
them  suppurate. 


774  ABNORMAL   PUERPERY. 

§  10.  Fistulse  of  the  Breasts. — -Two  kinds  of  fistulse  are  found 
in  the  breasts  of  nursing  women ;  one  is  a  remnant  of  an  abscess 
that  has  not  closed,  and  is  mostly  found  in  the  gland  or  in  the 
subglandular  space,  rarely  under  the  skin.  The  secretion  is  pus. 
The  other  is  a  milk  fistula,  a  fistulous  tract  leading  from  the  skin  to 
a  lactiferous  duct.  This  kind  may  also  have  originated  in  a  mammary 
abscess  which  corroded  a  milk-duct.  In  other  cases  it  is  due  to  an 
injury  by  which  such  a  duct  was  wounded.  The  secretion  may  be 
pure  milk  or  milk  more  or  less  mixed  with  pus. 

Such  old  fistulous  tracts  may  cause  a  considerable  drain  on  the 
strength  of  the  patient  and  predispose  to  tubercular  infection  of  the 
lungs. 

Treatment. — If  the  patient  nurses,  the  child  should  be  weaned. 
Pressure  should  be  exercised  with  pads  over  the  course  of  the  fistula. 
Astringent  and  irritant  fluids  should  be  injected  into  the  tract,  such 
as  undiluted  tincture  of  iodine  ;  or  a  2  per  cent,  solution  of  nitrate  of 
silver,  used  two  or  three  times  a  week ;  or  Villate's  solution  : 

R    Cupri  sulphatis, 

Zinci  sulphatis,  aa  ^ii  (8  grammes)  ; 

Sol.  plumbi  subacetatis,   ^ss  (15  grammes)  ; 

Aceti,  5  iij  (90  grammes). 
Sig. — To  be  mixed  with  twice  as  much  water; 

or  Labarraque's  solution  (liquor  sodse  chloratae,  U.S. P.),  a  fluidrachm 
of  which  is  mixed  with  an  ounce  of  water.  With  these  mixtures  the 
fistula  is  injected  two  or  three  times  a  day.  It  is  also  well  to  irrigate 
the  fistulous  tract  with  a  two  per  cent,  solution  of  carbolic  acid  once 
a  day.  If  there  is  room  enough  the  fistula  should  be  scraped  with 
Simon's  sharp  spoon  and  injected  with  iodoform  glycerin  (10  per 
cent.).  If  nothing  else  helps,  the  whole  fistulous  tract  should  be  laid 
open,  scraped,  and  dressed  antiseptically. 

§  11.  Galactocele. — In  very  rare  cases  the  aperture  of  a  lactifer- 
ous duct  is  occluded,  secretion  continues,  the  duct  is  at  first  dilated, 
and  finally  ruptures.  As  a  rule,  such  milk  tumors  are  small,  but  a 
case  has  been  reported  in  which  the  breast  hung  down  to  the  groin 
and  contained  ten  pounds  of  fluid. 

In  the  beginning  the  fluid  consists  of  pure  milk,  but  later  the 
serum  separates,  the  solid  parts  become  inspissated,  or  bursting 
blood-vessels  in  the  wall  mix  their  contents  with  it  and  produce  a 
variety  of  colors. 

The  diagnosis  may  be  difficult.  Before  rupture  the  tumor  may 
be  taken  for  a  cyst ;  after  rupture  it  feels  like  an  abscess.  Explora- 
tory puncture  will  decide. 

Treatment. — Simple  puncture  does  not  suffice.      Injection  of  tine- 


DISEASES    OF   THE    BREASTS.  775 

ture  of  iodine  may  produce  sufficient  adhesive  inflammation  to  close 
the  cavity.  If  not,  this  must  be  laid  open  and  left  to  close  by  gran- 
ulation. 

§  12.  Hypertrophy  of  the  Breasts. — Two  conditions  of  life  have 
a  marked  influence  on  the  production  of  hypertrophy  of  the  breasts — 
puberty  and  pregnancy.  That  of  puberty  is  much  more  serious,  since 
it  hardly  can  be  cured  in  any  other  way  than  by  amputation. 

That  of  pregnancy  begins,  as  a  rule,  rather  early,  and  continues 
during  the  whole  period  of  gravidity  and  lactation,  but,  as  a  rule,  it 
then  stops,  and  the  breast  resumes  gradually  its  normal  dimensions. 

All  the  elements  composing  the  breasts  increase  evenly,  without 
structural  change.  Both  breasts  may  be  affected  or  only  one,  or  one 
much  more  than  the  other.  Some  women  have  the  hypertrophy  in 
every  pregnancy.  The  breasts  may  become  so  enormous  that  they 
hang  down  to  the  middle  of  the  thighs,  and  nearly  equal  the  rest  of 
the  body  in  weight.  When  the  breast  grows  it  sinks  down  and  forms 
a  pedunculated  tumor.  The  areola  enlarges  in  circumference,  and 
the  nipple  is  flattened  out.  When  the  breast  becomes  heavy  it  drags 
on  the  pedicle  and  causes  pain.  When  it  becomes  very  large  the  skin 
covering  it  is  apt  to  become  inflamed  and  be  the  seat  of  abscesses, 
erysipelas,  or  gangrene.  The  patient  has  difficulty  in  breathing,  loses 
her  appetite,  and  becomes  cachectic. 

Pregnancy  is  often  interrupted  by  premature  labor.  The  foetus 
sometimes  dies  in  utero  or  the  child  is  puny  and  weak. 

The  secretion  of  milk  begins  sometimes  during  pregnancy,  and  as 
much  as  six  or  seven  ounces  has  been  milked  out  daily.  In  other 
cases  the  secretion  begins  as  usual  after  the  birth  of  the  child.  In 
most  cases  the  woman  cannot  nurse  on  account  of  the  shape  of  the 
nipple,  and  then  the  secretion  ceases  in  the  course  of  a  month  or  two. 
If,  on  the  other  hand,  the  patient  can  nurse,  the  secretion  continues 
normally,  and  nursing  may  be  kept  up  for  a  whole  year.  When  it  is 
discontinued,  or  if  it  is  not  begun  at  all,  the  breasts  retrograde  and 
finally  resume  normal  proportions. 

Treatment. — As  soon  as  the  breasts  assume  undue  proportions  they 
should  be  kept  up  and  compressed  with  the  breast-binder  and  a  suit- 
able corset.  Ointments  containing  iodine  or  iodide  of  potassium,  or 
both,  may  be  tried,  but  do  not  seem  to  have  much  effect.  Intercur- 
rent inflammation  of  the  skin  should  be  treated  according  to  the  gen- 
eral rules  of  surgery.  If  the  general  health  suffers  seriously,  it  may 
be  indicated  to  induce  premature  labor  or  even  artificial  abortion. 
But  under  no  circumstances  should  the  breast  be  amputated.  If  the 
woman  can  nurse  she  may,  but  hor  breast  will  need  artificial  support. 
After  the  child  is  weaned,  or,  if  the  patient  does  not  nurse,  imme- 
diately after  confinement,  involution  may  be  furthered  by  support, 


776  ABNORMAL    PUERPERY. 

compression,  resolving  embrocations  and  ointments,  and  the  internal 
use  of  iodide  of  potassium. 

Instead  of  producing  hypertrophy  of  tlie  breasts,  pregnancy  may 
be  a  cure  for  it.  A  curious  case  of  this  kind  is  on  record  in  wliich 
a  hypertropliy  that  had  existed  since  puberty  diminislied  gradually 
from  the  first  pregnancy  and  disappeared  totally  after  the  third.  Since 
the  alternative  is  amputation,  perhaps  young  girls  may  sometimes 
prefer  to  try  marriage. 


CHAPTER   V. 

DISEASES    OF    THE   UROPOIETIC    ORGANS. 

§  1.  Retention  of  Urine. — Retention  of  urine,  or  ischuria,  is  a 
rather  common  occurrence  in  childbed.  Sometimes  it  seems  to  be 
due  to  mere  lack  of  innervation.  Thus,  I  have  found  it  in  most  cases 
where  perineorrhaphy  has  been  performed.  At  other  times  it  may 
be  due  to  a  kink  in  the  urethra,  caused  by  the  sudden  subsidence  of 
the  uterus  and  bladder  after  the  expulsion  of  the  fcetus.  If  labor  is 
hard,  and  especially  if  it  has  to  be  finished  artificially,  the  urethra, 
squeezed  between  the  head  and  the  pubic  arch,  easily  becomes  bruised 
and  subsequently  swollen.  An  inflammation  of  the  vulva  may  extend 
to  the  urethra  and  make  it  swell.  If  peritonitis  develops  and  the 
peritoneal  coat  of  the  bladder  is  implicated  in  it,  the  wall  may  become 
oedematous  and  the  detrusor  muscle  paralyzed. 

Treatment. — In  all  these  cases  the  urine  may  with  facility  be  drawn 
with  a  catheter,  but  catheterization  in  childbed  has  the  great  draw- 
back that,  on  account  of  the  lochial  discharge,  it  easily  gives  rise  to 
cystitis.  If  ever  possible,  it  should  therefore  be  avoided.  There  are 
little  tricks  which  often  help  one  out  of  the  difficulty.  Ry  pouring 
into  the  bedpan  hot  water  or,  still  better,  an  infusion  of  chamomile 
flowers,  which  has  more  effect  on  the  imagination  than  plain  water, 
the  vapor  rises  against  the  genitals  and  induces  a  desire  to  urinate. 
Or  cold  water  may  be  poured  over  the  vulva.  Many  people  can 
urinate  readily  if  they  hear  the  water  run  from  a  faucet  into  a  basin. 
If  this  does  not  help,  and  the  patient  is  in  good  condition,  we  may  let 
her  sit  on  a  chamber-pot  in  bed  or  even  get  out  of  bed  and  use  a 
commode. 

If  it  becomes  necessary  to  use  the  catheter,  the  patient  should 
he  on  her  back,  the  vulva  should  be  spread  wide  open  and  carefully 
washed  with  a  copious  amount  of  some  disinfectant  fluid, — for  in- 
stance, a  1  per  cent,  mixture  of  lysol  and  water, — and  a  catheter 
made  aseptic  by  boiling  or  chemicals  should  be  introduced  with  the 
greatest  gentleness  in  a  circular  direction. 


DISEASES   OF   THE   UROPOIETIC    ORGANS.  777 

§  2.  Incontinence. — A  minor  degree  of  inability  to  retain  the 
urine  is  not  very  rare  among  lying-in  women.  Especially  during 
the  act  of  coughing  a  little  urine  may  escape  involuntarily.  This  is 
doubtless  due  to  the  contusion  of  the  urethral  sphincter  muscles  by 
pressure  between  the  head  of  the  foBtus  and  the  pubic  arch.  This 
weakness  passes  off  in  a  few  days,  and  restoration  to  the  normal 
power  may  be  furthered  by  the  administration  of  strychnine  (gr. 
y-g — 4  milligrammes — t.  i.  d.). 

If  the  urine  escapes  continually,  the  cause  is  probably  a  fistula, 
about  which  presently  more  will  be  said. 

§  3.  Cystitis. — Inflammation  of  the  bladder  is  not  rare  in  child- 
bed. It  is  due  to  microbic  invasion,  especially  by  a  diplococcus 
much  like  the  gonococcus.  As  a  rule,  the  infecting  agent  is  pres- 
ent in  the  lochial  discharge  and  carried  with  a  catheter  into  the 
bladder. 

The  inflammation  may,  however,  also  appear  in  cases  in  which 
no  catheter  has  been  used,  and  is  then  due  to  the  active  entrance 
of  the  microbes  through  the  urethra,  especially  if  the  vulva  is  in- 
flamed. Contusion  of  the  bladder  during  labor  does  not  by  itself 
produce  cystitis,  but  bruised  tissue  is  a  favorable  soil  for  the  germs 
of  disease.  As  some  time  is  needed  for  incubation,  the  inflammation 
does  not  appear  before  several  days  or  even  in  the  second  week  after 
confinement. 

Cystitis  is  characterized  by  pain  in  the  hypogastric  region,  frequent 
desire  to  urinate,  pain  during  micturition  and  especially  at  the  end  of 
the  act.  The  urine  is  turbid  and  forms  a  sediment  composed  of  pus- 
corpuscles. 

In  most  cases  it  is  a  disease  of  little  importance  and  curable  in  a 
few  days  or  a  couple  of  weeks ;  but  sometimes  the  inflammation 
extends  upward  through  the  ureters  to  the  pelves  of  the  kidneys  and 
to  these  glands  themselves.  It  is  particularly  when  the  urine  has  an 
offensive  odor  that  this  ascension  may  be  feared.  Pyelitis  and  nephri- 
tis are  ushered  in  by  high  fever  and  pain  in  the  lumbar  region.  Mi- 
croscopical examination  shows  the  characteristic  epithelial  cells  of  the 
ureter  and  the  kidney,  which  differ  from  those  of  the  bladder.  The 
fever  may  subside  in  a  week  or  two,  but  it  is  apt  to  return  after  inter- 
vals of  weeks  or  months. 

Treatment. — The  patient  must  abstain  from  spiced  food  and  alco- 
hohc  drinks.  She  should  have  plenty  of  fresh  water,  mineral  waters, 
and  milk.  French  Vichy,  half  a  tumblerful  at  a  time,  a  quart  a 
day,  is  particularly  soothing.  Among  the  domestic  waters  Poland, 
Bethesda,  Waukesha,  and  Buffalo  lithia  water  are  useful  by  producing 
a  copious  diuresis.  The  following  mixture  is  a  favorite  prescription 
of  mine  : 


778  ABNORMAL    PUERPERY. 

R    Tinct.  belladonnae,   ^ii  (8  grammes)  ; 
Liq.  potassse,   51  (30  grammes)  ; 
Aqu«  dest.,  q.  s.  ad  siv  (120  grammes). — M. 
Sig. — A  teaspoonful  in  a  wineglassful  of  water  four  times  a  day. 

Other  good  remedies  are  salicylate  of  sodium  (gr.  xv — 1  gramme 
— t.  i.  d.),  salol  (gr.  x-xy — from  60  centigrammes  to  1  gramme — t.  i.  d.), 
and,  if  the  urine  is  alkaline,  the  saturated  solution  of  boric  acid  (gss 
— 15  grammes — four  to  six  times  a  day),  or  benzoate  of  ammonium 
or  sodium  (gr.  v  to  xx — from  30  to  120  centigrammes — every  four 
hours).  Opiates  may  be  necessary  to  combat  pain,  especially  sup- 
positories with  pulvis  opii  (gr.  i — 6  centigrammes).  If  there  is  a  bad 
smell  to  the  urine,  cystogen  (gr.  v  in  tablet)  or  urotropine  (a  tablet 
with  gr.  viiss — 50  centigrammes),  that  is  formalin,  works  like  a  charm. 
A  warm  linseed-meal  poultice  placed  over  the  hypogastric  region,  and 
renewed  every  two  hours,  is  very  grateful.  In  order  not  to  carry 
new  infecting  germs  into  the  bladder,  it  is  better  to  avoid  irrigation, 
but  if  the  inflammation  does  not  yield  to  treatment  by  the  mouth,  the 
bladder  should  be  washed  out.  The  drug  I  ordinarily  use  is  boric 
acid  (|-2  per  cent.).  As  this  dissolves  with  difficulty  in  water,  a 
saturated — that  is  4  per  cent. — solution  should  be  made  and  mixed 
with  from  seven  to  equal  parts  of  lukewarm  water.  The  injection 
is  repeated  daily.  About  a  pint  is  used  each  time.  Other  fluids 
that  may  be  used  are  chlorate  of  potassium  (2  per  cent.),  salicyhc  acid 
(1 :  300) ;  nitrate  of  silver,  carbolic  acid,  creolin,  lysol  (all  1  :  500) ; 
and  thymol  (1  :  1200). 

§  4.  Fistulse. — A  fistula  is  an  abnormal  opening  leading  from 
the  genital  canal  to  the  urinary  tract  or  the  intestine. 

According  to  the  nature  of  the  extraneous  matter  that  finds  its 
way  into  the  genital  canal,  fistulas  are  divided  into  urinary  and  fecal. 

A.  Urinary  fistul^e  are  again  divided,  according  to  the  organs 
brought  into  abnormal  connection  with  one  another,  into,  1,  vesico- 
vaginal; 2,  urethrovaginal;  3,  ureterovaginal ;  4,  vesico-uterine ;  5, 
vesico-uterovaginal ;  6,  uretero-uterine ;  and,  7,  ureterovesicovaginal. 

There  may  be  one  or  more  fistula?,  and  in  size  they  vary  from  a 
scarcely  visible  aperture  to  an  opening  admitting  two  fingers. 

The  most  common  is  the  vesicovaginal  fistula. 

By  far  the  most  frequent  cause  of  all  kinds  of  fistulcB  is  childbirth. 
The  mechanism  may  be  twofold.  The  abnormal  communication 
may  be  due  to  a  tear,  when  it  appears  immediately  after  delivery  ;  or 
it  may  be  produced  by  pressure  and  consequent  necrosis.  In  the 
latter  case  the  fistula  does  not  occur  before  days  or  even  weeks  have 
elapsed  since  parturition  took  place.  At  the  time  of  delivery  the 
parts  become  bruised,  mortification  gradually  develops,  and  finally 
the  dead  plug  is  expelled,  leaving  a  hole. 


DISEASES    OF   THE    UROPOIETIC    ORGANS.  779 

Tears  are  especially  found  in  old  primiparae  or  after  the  use  of 
ergot  or  in  cases  in  which  the  forceps  was  applied  before  the  cervix 
was  sufficiently  dilated.  Pressure  is  due  to  a  disproportion  between 
the  foetus  and  the  genital  canal,  a  distended  bladder,  a  loaded  rectum, 
a  stone  in  the  bladder,  abnormal  presentation,  etc.  The  tissues 
withstand  much  better  the  same  degree  of  pressure  if  it  is  exercised 
for  a  short  time.  Pressure  listulae  are  therefore,  as  a  rule,  not  due  to 
the  use  of  the  forceps,  but  to  improper  delay  in  their  application.  As 
soon  as  the  presenting  part  becomes  impacted  and  does  not  move  to 
and  fro  during  and  between  labor-pains,  artificial  help  ought  to  be 
given.  In  consequence  of  the  improved  obstetrics  and  the  more 
frequent  use  of  the  forceps,  fistulae  have  become  much  rarer  than 
formerly,  and  the  patients  come  mostly  from  remote  localities,  where 
proper  assistance  during  labor  is  not  available. 

Symptoms. — The  chief  symptom  of  a  urinary  fistula  is  the  more  or 
less  constant  dribbling  of  urine  from  the  vagina,  but  this  does  not 
suffice  for  a  diagnosis,  since  the  same  takes  place  if  the  sphincters  of 
the  urethra  are  paralyzed ;  and,  on  the  other  hand,  if  the  urinary 
fistula  is  situated  high  up  in  the  partition  between  the  bladder  and  the 
genital  canal,  the  urine  may  be  retained  for  a  long  time  when  the 
woman  is  in  the  erect  posture,  and  in  urethrovaginal  fistulae  it  may  be 
entirely  retained  except  during  voluntary  micturition. 

In  spite  of  the  utmost  cleanhness,  fistula  patients  have  a  dis- 
agreeable ammoniacal  odor. 

Diagnosis. — If  the  fistula  is  large,  it  may  be  felt  by  digital  exami- 
nation of  the  vagina.  In  most  cases  it  can  be  seen  by  introducing 
a  speculum  and  placing  the  patient  in  different  positions,  especially 
Sims' s,  the  genupectoral,  and  the  dorsal  with  raised  knees  and  more 
or  less  elevated  pelvis. 

Sometimes,  however,  the  opening  is  so  minute  that  it  cannot  be 
seen,  or  it  may  be  hidden  by  a  projecting  fold  or  cicatrix.  In  such 
cases  the  presence  of  a  vesicovaginal  fistula  may  be  established  by 
injecting  a  colored  fluid — for  instance,  milk — into  the  bladder,  when 
the  fluid  will  appear  immediately  in  the  vagina. 

Since  the  ureters  cross  the  cervix  at  a  distance  of  about  ^  inch 
and  traverse  the  fornix  of  the  vagina,  fistulous  connections  between 
these  organs  may  originate  in  labor.  A  ureterovaginal  fistula  is 
situated  on  the  anterior  wall  of  the  vagina,  a  little  below  and  out- 
side of  the  vaginal  portion  of  the  uterus.  It  is  distinguished  from 
a  vesicovaginal  fistula  by  introducing  an  elastic  catheter,  which  if 
the  fistula  is  ureteral  can  be  pushed  deep  in  the  direction  of  the  cor- 
responding kidney,  and  urine  will  spurt  out  from  it  in  jets.  Milk 
injected  into  the  bladder  through  the  urethra  will  not  appear  in  the 
vagina,  but,  if  the  portion  of  the  ureter  between  the  fistula  and  the 


780  ABNORMAL    PUERPERY. 

bladder  is  pervious,  a  probe  introduced  through  the  fistula  may  be 
made  to  come  in  contact  in  the  bladder  with  a  sound  passed  through 
the  urethra. 

In  the  ureter o-uterine  fistula  there  is  an  opening  leading  from  the 
ureter  to  the  cervical  canal,  and  urine  passes  out  through  the  os 
uteri.  The  same  is  the  case  in  the  vesico-uterine  fistula,  where  there 
is  a  tear  through  the  anterior  wall  of  the  cervix  and  the  base  of  the 
bladder.  But  these  two  varieties  may  be  distinguished  from  each 
other  by  tlie  injection  of  milk  into  the  bladder.  If  the  communica- 
tion is  between  this  organ  and  the  cervix  the  milk  comes  out  through 
the  OS,  but  not  so  in  ureterocervical  fistula. 

The  vesico-uterovaginal  fistula  goes  from  the  bladder  through  the 
anterior  lip  of  the  cervix  and  ends  in  the  vagina. 

In  the  ureterovesicovaginal  fistula  there  is  a  vesicovaginal  fistula, 
which  implicates  the  ureter,  so  that  this  organ  opens  on  the  edge  of 
the  fistula. 

Prognosis. — Some  fistulse  close  by  tliemselves,  especially  the 
vesico-uterine.  In  other  cases  the  opening  generally  becomes  much 
smaller  than  it  is  when  it  first  appears. 

Treatment. — During  the  puerperium  there  is  not  much  to  be  done, 
except  to  keep  the  parts  clean  by  vaginal  antiseptic  injections.  Small 
fistulae  may  atter  the  first  nine  days  be  painted  with  tinctura  can- 
tharidis  or  cauterized  with  lunar  caustic,  nitric  acid,  or  carbolic  acid. 
Operations  should  be  postponed  until  the  parts  have  undergone  per- 
fect involution, — say  six  or  eiglit  weeks, — during  which  time  spon- 
taneous healing  may  occur,  or  the  fistula  will  at  least  become  much 
smaller  and  the  tissues  will  regain  their  normal  tone. 

B.  Fecal  Fistula. — A  fecal  fistula  constitutes  a  connection  be- 
tween the  genital  canal  and  some  part  of  the  intestine.  It  is  much 
rarer  than  urinary  fistula. 

The  abnormal  communication  may  take  place  between  the  rectum 
and  the  vulva — redovulvar  or  rectolabial  fistula — or  between  the  ileum 
or  the  sigmoid  flexure  of  the  colon  and  the  vagina  or  the  uterus — 
enter ovaginal,  ileoraginal,  and  ileo-uterine  fistula. 

The  openmg  may  be  so  small  that  it  is  difficult  to  discover,  or 
large  enough  easily  to  admit  a  finger. 

The  opening  is  most  commonly  located  either  immediately  al30ve 
the  sphincter  ani  muscles  or  at  the  vault  of  the  vagina.  As  a  rule,  it 
is  found  on  the  posterior  wall  of  the  vagina,  but  the  enterovaginal 
variety  may  exceptionally  open  in  front  of  the  uterus. 

A  fecal  fistula  may  be  due  to  pressure  between  the  head  of  the 
foetus  and  some  bony  protuberance  in  the  pelvis.  It  may  also  be 
brought  about  by  rupture  of  the  uterus  or  the  vagina,  an  intestinal 
knuckle  being  caught  in  the  rent  and  becommg  necrotic.     Or  it  may 


DISEASES   OF   THE   CIRCULATORY    ORGANS.  781 

originate  in  diphtheritic  or  gangrenous  processes  arising  from  puer- 
peral infection. 

Symptoms. — The  escape  of  flatus  or,  when  the  bowels  are  loose, 
excrementitial  matter  soon  attracts  the  attention  of  the  patient  or  her 
nurse. 

Of  enterovaginal  fistulse  there  are  two  varieties  with  very  different 
symptoms.  If  the  opening  is  small,  they  do  not  differ  materially 
from  other  fecal  fistulse  ;  but  if  the  whole  circumference  of  the  intes- 
tine has  been  destroyed,  and  the  edge  coalesces  with  that  of  the  rent, 
forming  a  j:)rcfe/'?iafura/  anus,  all  the  faeces  find  their  way  through  the 
vagina.  If  the  affected  part,  as  usual,  is  the  ileum,  undigested  food 
mixed  with  bile  will  make  its  appearance  at  the  fistula  about  two 
hours  after  every  meal.  The  patient  loses  flesh  and  finally  dies  of 
starvation. 

Diagnosis. — Large  fecal  fistulse  may  be  felt ;  small  ones  may  be 
seen,  but  are  often  hard  to  find  on  account  of  their  diminutive  size. 
Probing  and  injection  of  colored  fluid  may  help  to  find  the  inner 
opening. 

In  an  enterovaginal  fistula,  a  whole  intestinal  knuckle  having  been 
destroyed,  there  may  be  two  openings  \\ath  a  so-called  spur  between 
them. 

Prognosis. — While  fresh  urine  is  entirely  innocuous,  faeces  abound 
in  a  variety  of  microbes,  which,  when  there  is  a  fecal  fistula,  enter  the 
vagina  and  may  give  rise  to  infection  during  the  puerperium.  This 
kind  of  fistula  has  a  greater  tendency  to  spontaneous  healmg  than 
urinary  fistulse,  but,  on  the  other  hand,  they  are  harder  to  close  by 
operation. 

Treatment. — What  has  been  said  about  urinary  fistulse  applies  also 
to  fecal  fistulse.  During  the  puerperium  the  paris  should  be  kept 
clean,  and  operation  deferred  till  after  complete  involution. 


CHAPTER   VI. 

DISEASES    OF    THE    CIRCULATORY   ORGANS. 

§  1.  Embolism  and  Thrombosis  of  Arteries. — Arteries  may  be- 
come obstructed  by  the  arrest  of  an  embolus  in  their  lumen  or  a 
coagulation  of  the  blood,  or  both  combined.  Such  conditions  have 
been  found  in  the  cerebral  arteries,  the  humeral,  the  femoral,  the 
popliteal,  the  anterior  tibial,  the  dorsal  artery  of  the  foot,  and  even 
in  the  aorta  and  both  common  iliac  arteries. 

Etiology. — A  piece  of  a  vegetation  on  the  valves  of  tlie  heari  may 
be  detached  and  carried  by  the  blood-current  to  some  more  or  less 


782  ABNORMAL    PUERPERY. 

remote  locality.  These  vegetations  may  be  of  old  date  and  due 
to  rheumatism,  or  they  may  have  formed  during  the  puerperium  in 
consequence  of  puerperal  infection  and  endocarditis. 

The  wall  of  an  artery  may  become  inflamed  and  roughened,  and 
this  may  cause  stagnation  and  coagulation  of  the  blood,  which  itself 
is  more  apt  to  undergo  such  changes  during  the  puerperium  on  account 
of  the  altered  chemical  composition  of  the  blood  and  the  weakness 
and  slowness  of  cardiac  contraction. 

Symptoms. — The  symptoms  of  arterial  obstruction  vary  with  the 
site  and  the  completeness  or  incompleteness  of  the  barrier  to  circula- 
tion. I  have  seen  sudden  death  occur  from  closure  of  the  basilar 
artery.  Sudden  blindness  followed  by  destruction  of  the  eyeball  is 
probably  due  to  the  occlusion  of  the  ophthalmic  artery.  If  the  mid- 
dle cerebral  artery  is  blocked  up,  hemiplegia  of  the  opposite  half  of 
the  body  occurs,  followed  by  softening  of  the  corresponding  part  of 
the  cerebrum.  In  a  case  in  which  a  thrombus  occupied  the  lower 
part  of  the  abdominal  aorta  and  both  common  iliac  arteries,  both 
lower  extremities  became  gangrenous. 

However,  even  the  complete  obliteration  of  the  lumen  of  the 
chief  artery  of  a  limb  need  not  necessarily  lead  to  gangrene.  Gener- 
ally, a  collateral  circulation  is  established,  and  it  is  only  when  this 
too  is  interrupted,  or  the  corresponding  veins  become  impervious, 
that  local  death  must  ensue. 

A  chief  symptom  of  arterial  obstruction  is  pain,  which  may  be 
very  severe  and  sometimes  has  the  neuralgic  type.  The  affected  part 
becomes  cold  and  numb.  Pulsation  is  abolished  below  the  seat  of 
the  obstruction  and  increased  in  volume  above  it.  If  the  occluding 
body  is  an  embolus,  the  arrest  of  pulsation  may  occur  suddenly.  If 
it  is  a  slowly  forming  thrombus,  the  disappearance  is  gradual. 

Prognosis. — It  results  from  what  has  just  been  said  that  arterial 
occlusion  is  a  grave  accident,  which  may  lead  to  local  mortification, 
great  functional  disturbances,  or  death. 

Treatment. — Art  can  do  very  little  in  this  sad  conjuncture.  Ab- 
solute rest  of  the  affected  portion  of  the  body  is  indicated  in  the 
hope  of  favoring  the  establishment  of  a  collateral  circulation  and  the 
absorption  of  a  thrombus.  The  severe  pain  calls  for  powerful  ano- 
dynes. The  affected  limb  should  be  covered  with  hot  cloths  soaked 
in  some  stimulating  fluid,  such  as  infusion  of  hops,  chamomile  flowers, 
or  wine.  The  patient's  strength  should  be  kept  up  by  tonics,  strong 
wine,  and  generous  food.  If  gangrene  supervenes,  we  should  await 
the  formation  of  a  line  of  demarcation  and  then  amputate  somewhat 
higher  up. 

§  2.  Thrombosis  and  Embolism  of  the  Venous  System ;  Heart- 
Clot. — We  have  already  spoken  of  thrombosis  and  embolism  in  the 


DISEASES    OF   THE    CIRCULATORY    ORGANS.  783 

venous  system  in  connection  with  puerperal  infection  (see  pp.  706, 
714).  We  have  particularly  dwelt  on  the  disease  called  phlegmasia 
alba  dolens,  which  often  is  due  to  venous  thrombosis  beginning  at 
the  placental  site.  But  apart  from  infection  the  blood  may  coagulate 
in  different  parts  of  the  venous  system,  inclusive  of  the  right  side 
of  the  heart  and  the  pulmonary  arteries,  and  give  rise  to  protracted 
illness,  severe  suffering,  or  sudden  death. 

Thrombosis  of  the  Lower  Extremity. — Isolated  thrombosis  of  the  leg 
is  not  rare  during  pregnancy.  In  the  puerperium  such  a  pre-existing 
thrombus  may  increase  in  size  or  new  ones  may  develop.  It  begins 
ordinarily  in  the  second  week  after  childbirth,  and  generally  in  a  su- 
perficial vein  of  the  calf  or  in  the  popliteal  space.  Sometimes  it  starts 
in  varicose  veins.  The  slow  pulse  ;  the  general  weakness  ;  the  feeble 
cardiac  contractions ;  the  chemical  composition  of  the  blood,  which 
contains  a  superabundance  of  fibrin  and  is  charged  with  effete  mate- 
rial from  the  uterus,  that  is  undergoing  involution  ;  the  rest  in  bed; 
the  absence  of  muscular  activity, — all  are  circumstances  normahy 
connected  with  the  puerperal  state,  but  which  predispose  to  stagna- 
tion and  coagulation  of  the  blood.  The  amount  of  fibrin  in  the  blood 
is  in  the  unimpregnated  state  about  3  per  1000.  During  the  first  six 
months  of  pregnancy  it  decreases  to  2|  or  2f  per  1000,  but  during 
the  last  three  months  it  rises  to  4  or  more. 

To  these  physiological  conditions  may  be  added  pathological  pro- 
cesses that  enhance  the  tendency  to  thrombosis.  The  heart  may  be 
weakened  by  fever.  The  free  circulation  may  be  impeded  by  pelvic 
exudation.  There  may  have  been  loss  of  blood  during  or  after 
labor,  which  increases  the  coagulability  of  the  blood.  In  a  case  in 
which  all  four  extremities  were  bandaged  during  nineteen  hours  on 
account  of  inversion  of  the  uterus,  thrombi  developed  in  the  legs. 

Symptoms. — The  affected  part  of  the  vein  is  felt  as  a  hard  string, 
sensitive  to  touch.  There  may  also  be  some  spontaneous  pain.  If 
one  of  the  larger  veins,  such  as  the  femoral,  the  popliteal,  or  the 
saphenous,  becomes  impervious,  there  is  swelling  of  the  extremity, 
beginning  from  the  foot  and  gradually  extending  upward',  and  con- 
siderable pain.  The  thrombus  has  no  tendency  to  implicate  the  pel- 
vic veins.     There  is  ordinarily  no  fever. 

The  thrombus  is  generally  absorbed  with  restitution  of  the  circu- 
lation of  the  blood  through  its  lumen  ;  or  it  may  become  organized, 
closing  the  vein  permanently.  The  resolution  takes  from  two  to  three 
weeks.  In  rare  cases  the  thrombus  may  irritate  the  vein,  causing 
phlebitis  and  periphlebitis,  which  may  end  in  an  abscess  that  breaks 
through  the  skin.  The  inflammation  is,  of  course,  accompanied  by 
rise  in  temperature. 

The  treatment  has  been  described  above  (p.  745). 


784  ABNORMAL   PUERPERY. 

Thrombosis  of  the  veins  of  the  upper  part  of  the  thigh  may  be 
brought  on  by  simple  extension  of  a  non-infected  thrombus  of  the 
pelvic  veins  (p.  706).  This  condition,  known  as  phlegmasia  alba  dolens, 
is  characterized  by  swelling,  beginning  at  the  upper  end  of  the  thigh, 
and  considerable  pain.  Sometimes  the  thrombosis  is  ushered  in  by 
a  chill.  In  the  course  of  about  three  days  the  whole  extremity  is 
swollen.  At  the  end  of  a  week  detumescence  begins ;  but  some- 
times, after  a  lapse  of  ten  days  to  two  weeks,  the  other  leg  be- 
comes affected  in  a  similar  way  either  by  extension  of  the  throm- 
bosis to  the  vena  cava  or  by  a  new  thrombus  forming  independently 
on  the  other  side.  It  may  therefore  take  a  month  or  two  before  re- 
covery is  complete. 

Venous  thrombosis  may  lead  to  embolism  of  the  pulmonary  ar- 
tery or  to  gangrene. 

Embolism. — A  piece  of  a  thrombus  may  be  broken  off  and  car- 
ried to  the  right  side  of  the  heart  or  through  it  into  the  pulmonary 
artery.  Generally  it  is  arrested  at  the  bifurcation,  where  the  passage- 
way suddenly  narrows.  It  consists  of  a  grayish-white  mass  that  some- 
times fits  exactly  to  the  thrombus  in  the  lower  extremity  from  which 
it  has  been  broken  off.  If  the  embolus  obstructs  the  whole  artery, 
sudden  death  must  ensue ;  but  if  the  obstruction  is  only  partial,  life 
may  continue  and  the  fibrin  of  the  passing  blood  is  precipitated  in  layers 
around  the  embolus.  The  outer,  fresh  layers  are  harder  than  the 
centre,  which  becomes  softened.  If  the  patient  lives,  the  clot  may 
be  reabsorbed,  shrinking  to  a  band  or  a  thread,  and  finally  disap- 
pearing. Sometimes  the  clot  lies  loose,  in  other  cases  it  adheres  to 
the  wall. 

There  is  hardly  any  doubt  that,  as  a  result  of  the  same  causes 
which  produce  a  thrombus  in  the  lower  extremities,  a  dot  may  also 
form  primarily  in  the  heart  or  in  the  pulmonary  artery  or  its  branches. 
Such  a  thrombus  may  begin  in  the  smaller  ramifications  of  the  pul- 
monary artery  and  gradually  grow  backward  towards  the  heart,  ter- 
minating with  a  rounded-off  end.  In  other  cases  it  seems  to  have 
begun  in  the  heart  itself,  to  the  inside  of  which  it  is  fastened,  while  a 
band-like  prolongation  hangs  loose  in  the  pulmonary  artery. 

Symptoms. — Whether  the  clot  is  formed  by  an  embolus  coming 
from  a  distance  or  by  thrombosis  of  the  heart  and  pulmonary  ar- 
tery themselves,  has  only  little  influence  on  the  symptoms.  Em- 
bolism occurs,  however,  later  than  autochthonic  thrombosis.  The 
former  has  not  been  observed  before  the  nineteenth  day  after  con- 
finement, while  the  latter  appears  within  a  fortnight  and  often  ends 
in  death  on  the  second  or  third  day  of  the  puerpery.  In  embolic 
cases  signs  of  phlegmasia  precede  the  attack,  while  in  thrombosis  they 
may  develop  subsequently.      Thrombosis  is  likely  to  develop  more 


DISEASES   OF   THE    CIRCULATORY    ORGANS.  785 

gradually,  whereas  the  lodging  of  an  embolus  in  the  pulmonary  artery 
will  precipitate  symptoms  and  may  end  in  death  in  a  few  minutes. 

The  most  striking  symptom  is  the  sudden  appearance  of  the  most 
terrific  dyspnoea.  Respiration  is  hurried.  The  patient  gasps  for 
breath,  throws  back  the  cover,  tears  the  clothes  from  her  chest.  All 
inspiratory  muscles  contract  forcibly.  Sometimes  convulsions  occur. 
The  face  is  either  deadly  pale  or  deeply  cyanosed.  The  action  of  the 
heart  becomes  tumultuous  and  irregular.  The  pulse  becomes  thread- 
like. Temperature  falls  below  normal.  Over  the  pulmonary  artery 
may  be  heard  a  blowing  or  rasping  murmur.  Sometimes  swelHng  of 
the  face  and  neck  has  been  noticed.  The  intellect  remains  clear.  In 
cases  that  do  not  end  in  immediate  death  there  may  be  repeated 
attacks,  especially  after  unusual  exertion,  such  as  sitting  up  in  bed  or 
rising.  Death  is  due  to  asphyxia.  It  is  true  the  air  can  be  heard  to 
enter  the  lungs,  but  the  blood  cannot  reach  it,  or  at  least  not  over  a 
sufficiently  large  area  or  in  sufficient  quantity  to  be  fully  oxygenated. 
Death  may  be  almost  instantaneous  or  occur  after  several  days.  In 
other  cases  recovery  is  established  gradually. 

In  several  instances  the  attack  began  during  an  inunction  for  throm- 
bosis of  the  lower  extremity.  Sometimes  an  increased  frequency  of 
pulsation  and  a  rise  of  temperature  have  preceded  the  attack. 

Treatment. — The  prophylaxis  consists  in  rest  when  there  is  throm- 
bosis anywhere  in  the  body,  and  in  avoidance  of  manipulations  that 
might  dislodge  a  thrombus  or  break  off  a  piece  from  it.  It  is,  there- 
fore, not  safe  to  rub  resolvent  ointment  into  the  skin  over  the  throm- 
bus. Only  substances  that  can  be  painted  on  with  a  brush,  such  as 
tincture  of  iodine,  oleate  of  mercury,  or  a  fluid  mixture  of  blue  oint- 
ment and  oil,  should  be  employed. 

If  an  embolus  has  lodged  in  the  pulmonary  artery  or  a  heart-clot 
has  formed,  our  resources  are  sadly  restricted.  Sometimes  death 
occurs  with  such  lightning  haste  that  there  is  no  time  for  any  thera- 
peutic measures.  Under  more  favorable  circumstances  the  first  indi- 
cation is  to  try  to  keep  the  patient  alive.  She  must  be  kept  quiet,  and 
even  nearly  motionless,  in  most  cases  in  a  recumbent  position  ;  but 
in  this  respect  we  must  observe  and  follow  nature  :  if  the  patient 
breathes  better  in  a  sitting  posture,  it  would  be  folly  to  force  her  to 
lie  down.  She  should  only  be  well  propped  uj)  in  the  posture  that 
interferes  least  with  respiration.  Alcoholic  drinks  seem  to  have  a 
better  effect  than  anything  else,  and  should  be  given  freely  and  re- 
peated frequently.  Hypodermic  injections  of  strychnine,  nitroglycerin, 
digitalis,  strophanthus,  and  atropine  may  also  prolong  life,  and  thus 
increase  the  chances  of  recovery. 

The  dyspnoea  may  perhaps  be  relieved  by  dry  cupping  of  the 
chest.    If  that  does  not  help,  wet  cupping  or  even  phlebotomy  should 

50 


786  ABNORMAL   PUERPERY. 

be  tried.  In  the  hope  of  resolving  tlie  clot,  aqua  ammonise  fortior 
rrix  (60  centigrammes)  mixed  with  aqua  destillata  sss  (15  grammes) 
may  be  injected  into  a  vein ;  and  of  common  aqua  ammonias  n^xx 
(1.30  grammes),  properly  diluted,  may  be  given  hourly  by  the  mouth. 

§  3.  Entrance  of  Air  into  the  Veins  of  the  Uterus. — During 
delivery  and  within  a  few  hours  after  the  end  of  labor  air  may  fmd 
its  way  into  the  veins  of  the  uterus  and  be  carried  through  the  vena 
cava  to  the  heart,  the  lungs,  and  even  into  the  arterial  system.  It 
has  been  found  in  all  parts  of  the  vascular  system,  most  frequently  in 
the  uterine  veins,  in  the  vena  cava  inferior,  in  the  cavities  of  the  heart, 
in  smaller  branches  of  the  pulmonary  artery,  and  in  the  coronary 
arteries. 

Many  features  of  childbirth  are  calculated  to  invite  and  favor  the 
entrance  of  air.  Even  in  normal  delivery,  Avith  the  Avoman  in  the 
dorsal  position,  air  enters  easily  through  the  large  gaping  vulva, 
vagina,  and  cervix.  By  its  normal  contractions  and  relaxations  that 
follow  the  expulsion  of  the  child,  the  uterus  may  pump  the  air  into 
the  cavity  like  a  suction-pump  ;  and  once  there,  if  the  entrance  is 
closed,  the  air  may  by  the  same  action  be  pressed  into  the  veins  of 
the  placental  site  as  with  a  force-pump.  Normally,  the  sinuses  of  the 
placental  site  are  closed  during  and  immediately  after  the  detachment 
of  the  placenta,  but  in  some  cases  of  entrance  of  air  into  the  veins 
they  have  been  found  gaping  with  openings  an  eighth  of  an  inch 
in  diameter.  In  the  semi-prone  and  still  more  in  the  knee-chest 
position,  the  uterus  sinking  upward  and  forward,  gravity  facilitates 
the  entrance.  If  we  introduce  the  hand  into  the  uterus  in  order 
to  perform  version  or  detach  an  adherent  placenta,  the  air  may  fol- 
low the  manipulating  hand  into  the  uterine  cavity.  Entrance  into  the 
veins  becomes  particularly  easy  during  version  for  placenta  prsevia,  in 
cases  of  rupture  of  the  uterus,  or  in  Csesarean  section  if  the  incision 
goes  through  the  placenta.  The  pumping  action  of  the  heart  may 
aspire  the  air.  When  a  great  quantity  of  liquor  amnii  is  discharged 
at  once,  air  may  rush  in  to  take  its  place.  Sometimes  the  air  has 
been  directly  pumped  into  a  uterus  in  giving  vaginal  or  intra-uterine 
injections. 

Many  different  theories  have  been  advanced  as  to  what  is  the  real 
cause  of  death  when  air  enters  the  venous  system.  Most  likely  it  is 
due  to  the  air  forming  emboh,  which  prevent  the  free  circulation 
and  oxygenation  of  the  blood  and  cause  asphyxia,  a  theory  which 
finds  a  solid  basis  in  the  great  similitude  in  the  clinical  aspect  of 
cases  of  solid  emboli  and  those  of  entrance  of  air.  Others  attribute 
the  sudden  death  to  anaemia  of  the  brain  or  paralysis  of  the  heart. 

Symptoms. — The  condition  is  characterized  by  sudden  terrific 
dyspnoea.     Sometimes  the  patient  utters  a  loud  cry,  in  others  she 


DISEASES    OF   THE    CIRCULATORY    ORGANS.  787 

dies  without  a  sound  as  if  struck  by  lightning.  If  the  course  is  less 
rapid  she  complains  of  severe  pain  in  the  chest,  and  may  have  rigors. 
In  rare  cases  the  dyspnoea  subsides  and  the  patient  recovers. 

Prognosis. — The  mortality  is  enormous.  Out  of  43  cases  39  ended 
fatally. 

Diagnosis. — Sometimes  a  crackling  sound  is  heard  in  moving  the 
hand  over  the  abdomen,  like  the  one  observed  in  emphysema,  and 
due  to  the  presence  of  air  in  the  veins  of  the  uterus.  If  present,  this 
sign  makes  the  diagnosis  certain. 

Treatment. — It  appears  from  the  above  that  it  is  safer  to  perform 
operations  in  which  the  hand  enters  the  uterus  with  the  patient  in  the 
dorsal  position.  This  applies  particularly  to  operative  interference  in 
cases  of  placenta  praevia  or  rupture  of  the  uterus.  If  in  normal  cases 
we  deliver  the  child  with  the  woman  in  the  left-side  position,  she 
should  immediately  after  expulsion  of  the  child  be  turned  on  her 
back.  Vaginal  and  intra-uterine  injections  should  always  be  given 
with  the  patient  lying  in  the  dorsal  position.  No  kind  of  pump  should 
be  used  for  these  injections  during  labor  and  in  the  puerperium,  but 
exclusively  fountain-syringes,  from  which  the  air  should  be  driven 
out  before  the  injection  is  made. 

If  thus  we  may  do  something  to  prevent  the  entrance  of  air  into 
the  veins,  we  are  almost  powerless  in  combating  it  when  it  has  taken 
place.  If  the  patient  does  not  die  immediately,  a  stimulating  treat- 
ment similar  to  that  described  for  heart-clot  should  be  instituted. 

§  4.  Gangrene  of  the  Legs. — In  speaking  of  arterial  and  venous 
obstruction  we  have  mentioned  that  it  may  lead  to  gangrene  ;  but  the 
accident  being  such  an  important  one  for  the  patient,  and  having  given 
rise  to  a  suit  for  damages,^  we  shall  enter  a  little  more  fully  on  the 
question. 

In  most  cases  the  gangrene  is  preceded  by  phlegmasia  alba 
dolens,  and  it  has  been  observed  where  the  veins  of  the  foot  alone 
and  no  arteries  were  affected.  In  other  cases  there  was  an  embolus 
in  an  artery  and  no  obstruction  in  the  veins,  and  in  others  again 
both  arteries  and  veins  were  blocked  up.  A  thrombus  or  embolus 
on  one  side  may  by  fibrinous  precipitation  extend  upward  and  reach 
the  aorta  or  vena  cava  and  descend  through  the  common  iliac  vessels 
to  the  other  extremity,  so  that  the  gangrene  becomes  double.  In 
one  case  all  the  toes,  the  fingers  of  one  hand,  and  an  ear  became  gan- 
grenous, which  may  have  been  due  to  Raynaud's  disease.  As  a  rule, 
the  gangrene  is  of  the  dry  variety  ;  the  humid  is  found  only  in  cases 
of  general  sepsis. 

Etiology. — An  embolus  may  be  torn  off  from  the  valves  of  the 
heart  when  there  previously  has  been  endocarditis,  or  it  may  come 

*  E.  Wormser,  Centralblatt  fiir  Gynakologie,  1900,  vol.  xxiv.,  No.  44,  p.  1154. 


788  ABNORMAL   PUERPERY. 

from  the  venous  system  through  an  open  foramen  ovale  of  the 
heart. 

Primary  arterial  thrombosis  may  start  at  the  placental  site  and 
extend  upward  to  the  common  iliac  artery  and  even  the  aorta  and 
the  common  iliac  on  the  other  side.  Venous  thrombosis  may  also 
begin  at  the  placental  site  or  in  the  extremity  itself;  but  in  order  that 
the  foot  shall  become  gangrenous  without  closure  of  the  external  or 
common  iliac  vein,  all  its  veins  must  be  blocked  up,  which  probably 
can  be  brought  about  only  by  that  increase  in  coagulability  towards 
the  end  of  pregnancy  and  in  the  puerperium  which  we  have  spoken 
of  above. 

If  the  obstruction  is  found  in  both  the  arterial  and  the  venous 
system,  the  development  of  gangrene  is,  of  course,  much  easier. 

Symptoms. — The  disease  begins  at  a  length  of  time  after  confine- 
ment varying  from  four  days  to  three  months  and  a  half.  In  cases 
of  embolus  the  start  is  sudden,  while  in  other  cases  the  development 
extends  over  several  days.  The  patient  complains  of  severe  pain  in 
the  affected  extremity.  The  limb  swells.  Sensation  is  lost.  General 
temperature  rises.  The  pulse  becomes  more  frequent,  and  it  may 
stop  altogether  in  the  threatened  limb.  The  skin  becomes  cold,  pale, 
and  later  dark  blue,  and  vesicles  filled  with  serum  may  rise  on  it. 
When  local  death  has  occurred,  the  pain  ceases.  As  a  rule,  a  distinct 
line  of  demarcation  is  soon  established. 

The  prognosis  as  to  life  seems  to  be  good,  except  when  there  is 
general  sepsis  or  no  hne  of  demarcation  forms  ;  but  the  gangrenous 
portion  of  the  limb  is,  of  course,  irretrievably  lost. 

Treatment. — Prevention  can  only  consist  in  elevating  the  limb  in 
which  there  is  an  obstruction,  strengthening  the  heart,  and  keeping 
the  threatened  part  warm.  As  soon  as  a  line  of  demarcation  is 
established,  amputation  in  the  healthy  tissue  should  be  performed. 
If  there  is  no  such  boundary  and  the  gangrene  spreads  rapidly,  it 
is  wise  to  do  the  same ;  but  then  the  outlook  for  a  good  result  is 
much  less  favorable. 

§  5.  Anaemia. — Great  loss  of  blood  immediately  after  confine- 
ment or  during  the  puerpery  may  lead  to  a  state  of  aneemia  that 
may  extend  over  months  and  even  years.  It  is  characterized  by 
the  pale  color  of  the  skin,  general  weakness,  and  a  weak,  rapid 
pulse.  In  regard  to  treatment,  we  may  refer  to  what  has  been 
said  about  the  later  stage  of  convalescence  after  post-partum  hemor- 
rhage (p.  515).  A  sea  voyage  on  a  sailing  vessel  or  a  slow  steamer, 
or  a  change  either  to  a  milder  or  a  more  bracing  climate,  is  also  to  be 
recommended ;  but  mountains  are  to  be  avoided  on  account  of  the 
low  atmospheric  pressure,  which  may  injuriously  affect  the  heart,  the 
brain,  or  the  kidneys. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  789 

CHAPTER   VII. 
DISEASES   OF   THE   NERVOUS    SYSTEM. 

§1.  Neuralgia  and  Pressure  Paralysis.  —  During  labor  some 
women  experience  a  violent  neuralgic  pain  in  one  of  the  lower  ex- 
tremities, which  is  due  to  pressure  on  the  sacral  plexus.  Sometimes 
the  pain  is  localized  in  the  area  of  the  peroneal  nerve  or  in  the  gluteal 
region,  corresponding  to  the  superior  gluteal  nerve.  In  some  cases 
the  leg  is  thrown  violently  up  during  each  uterine  contraction.  It  is 
especially  a  generally  contracted  pelvis  that  predisposes  to  such 
neuralgias,  while  in  a  flat  pelvis  the  protruding  promontory  protects 
the  nerve  trunks  against  pressure. 

The  same  pressure  that  causes  pain  during  labor  may  result  in  pare- 
sis, paralysis,  or  numbness  of  the  whole  lower  extremity  or  particular 
groups  of  muscles.  Thus  the  disturbance  may  be  limited  to  the  area 
innervated  by  the  peroneal  nerve,  which  is  explained  by  this  nerve 
originating  from  the  lumbosacral  cord,  which  receives  its  fibres  from 
the  fourth  and  fifth  lumbar  nerve,  and  crosses  the  brim  of  the  pelvis, 
where  it  may  be  exposed  to  isolated  pressure.  The  result  is  a  pa- 
ralysis of  the  anterior  and  outer  muscles  of  the  leg,  in  consequence 
of  which  the  foot  is  thrown  into  strong  plantar  flexion  and  curved 
inward. 

In  these  cases  the  paralysis  is  similar  to  that  occurring  in  the  upper 
extremity  of  a  person  who  falls  asleep  with  the  arm  hanging  over  the 
back  of  the  chair,  and  to  most  cases  of  what  has  been  described  as 
anaesthesia  paralysis.^  It  is  especially  frequent  after  forceps  delivery, 
but  has  been  observed  also  in  spontaneous  labor  with  vertex  or  face 
presentation.  In  most  cases  this  paresis  or  paralysis  from  pressure 
passes  off  in  a  few  days,  but  after  severe  injury  the  lameness  may 
remain  for  months  or  years.  Sometimes  hemiplegia  occurs  during 
delivery  or  in  the  puerperium,  which  is  due  to  apoplexy  or  embolism. 
Paraplegia  has  also  been  observed,  but  is  very  rare. 

Diagnosis. — In  cases  of  lameness  after  difficult  forceps  delivery  it 
should  be  remembered  that  rupture  of  the  symphysis  pubis  gives 
similar  symptoms. 

Treatment. — For  the  neuralgia  of  labor  recourse  must  be  had  to 
subcutaneous  injections  of  morphine  and  to  inhalation  of  chloroform. 

The  paralysis  should  be  treated  with  faradization,  massage,  hydro- 
therapeutics,  and  injection  of  strychnine  into  the  affected  muscles. 

§  2.  Neuritis  and  Polyneuritis. — In  some  of  the  above-mentioned 
cases  the  injured  nerves  may  become  inflamed,  and  the  inflammation 

1  Garrigues,  "  Anaesthesia  Paralysis,"  Amer.  Jour.  Med.  Sci.,  Jan.,  1897,  and 
Diseases  of  Women,  third  ed- .  p.  208. 


790  ABNORMAL   PUERPERY. 

may  extend  from  the  pelvis  to  the  inferior  extremity,  but  the  origin 
is  plainly  traumatic  and  referable  to  the  time  of  labor. 

In  other  cases  a  pelvic  exudation  brought  on  by  inflammation  fol- 
lowing labor  may  press  on  a  nerve  trunk  and  give  rise  to  pain  and 
lameness,  which  symptoms  will  then  begin  some  time  after  labor. 

In  other  instances,  again,  symptoms  of  neuritis  appear  from  one 
to  three  weeks  after  childbirth,  which  in  no  way  can  be  referred  to 
pressure  on  nerve  trunks  during  or  after  labor. 

The  affection  does  not  seem  to  be  very  rare,  since  a  comparatively 
large  number  of  cases — thirty-eight — has  been  reported  within  a  few 
years.  With  the  material  at  present  known,  two  forms  may  be 
distinguished, — a  localized  and  a  diffuse, — and  the  localized  is  again 
subdivided  into  an  arm  type  and  a  leg  type. 

The  localized,  or  lighter,  form  begins  for  the  most  part  in  the 
arms.  Either  one  or  both  upper  extremities  may  be  affected.  It 
is  especially  the  median  and  ulnar  nerves  that  become  the  seat  of 
the  disease.  More  rarely  the  lower  extremities,  and  then  generally 
only  one  of  them,  are  affected.  It  is  particularly  the  sciatic  nerve 
that  suffers.  Sometimes  the  neuritis  of  the  lower  limbs  is  consecutive 
to  that  of  the  upper.  The  muscles  of  the  trunk  may  also  be  affected. 
Symptoms. — The  affected  nerves  become  sensitive  to  pressure ; 
the  patient  suffers  great  pain.  In  some  cases  there  was  a  burning 
and  pricking  sensation  in  the  hands.  The  muscles  innervated  by  the 
inflamed  nerve  become  lame  or  paralyzed.  Sometimes  they  are 
contracted.  In  some  cases  the  affected  area  is  numb  or  anaesthetic, 
and  occasionally  the  seat  of  cramps.  Reflexes  may  undergo  changes. 
Often  the  affected  part  becomes  oedematous.  Later  the  muscles  atro- 
phy, and  the  nerves  show  the  reaction  of  degeneration. 

The  prognosis  in  this  form  is,  as  a  rule,  favorable,  the  disease 
ordinarily  ending  in  recovery. 

The  diffuse,  or  generalized,  form  is  much  rarer,  but  also  much  more 
severe.  The  cerebral  nerves  become  implicated.  There  may  be 
paralysis  of  the  eye  muscles,  diplopia,  and  vertigo.  Paralysis  of  the 
pneumogastric  nerve  causes  difficult  deglutition  and  respiration,  Avhich 
has  even  been  fatal.  But,  generally,  even  in  this  worst  form  the 
prognosis  is  better  than  one  would  expect  from  the  serious  condition 
present,  experience  having  shown  that  great  improvement  and  even 
complete  recovery  may  follow. 

The  etiology  is  by  no  means  clear  and  probably  not  uniform.  Loss 
of  blood,  anaemia,  alcoholism,  syphilis,  cachexia,  and  marasmus  seem 
to  have  been  at  least  predisposing  causes  in  some  cases.  Uncontrol- 
lable vomiting  in  pregnancy  may  also  give  rise  to  neuritis  after  the 
birth  of  the  child.  Some  cases  develop  in  connection  with  phlegmasia 
alba  dolens  ;  many  are  undoubtedly  of  septic  origin. 


DISEASES    OF   THE    NERVOUS   SYSTEM.  791 

Treatment. — Rest  in  bed  or  on  a  lounge  is  imperative.  In  the  be- 
ginning an  ice-bag  or  hot  apphcations  may  have  a  soothing  effect.  The 
hypodermic  injection  of  carbohc  acid  with  or  without  morphine  is  a 
more  active  cure. 

B   Acidi  carbolici,  tt^x  (60  centigrammes)  ; 

Morphinaj  sulphatis,  gr.  v  (30  centigrammes)  ; 
Aquae  destillatae,  "-i  (30  grammes). 

Of  this  mixture  ti^xv  are  injected  once  daily  deep  into  the  tissue, 
close  up  to  the  nerve.  Unguentum  hydrargyri  and  unguentum  bella- 
donnse,  equal  parts,  may  be  used  for  inunction  or  application.  Inter- 
nally the  sodium  salicylate,  salol,  iodides,  quinine,  iron,  arsenic,  and 
strychnine  are  indicated  as  resolvents  and  tonics.  Phenacetin,  anti- 
kamnia,  and  opiates  are  needed  to  combat  the  pain.  At  a  later  period, 
after  all  pain  has  ceased,  galvanism  and  faradism  should  be  used  to 
hasten  restitution  of  the  nerves  and  prevent  atrophy  of  the  muscles. 
The  electric  treatment  may  to  advantage  be  combined  with  massage 
and  passive  movements.  And  last  of  all  recourse  may  be  had  to 
active  gymnastics. 

If  there  is  a  pelvic  exudation,  this  should  be  combated  with  hot 
douches,  ichthyol  glycerin,  tincture  of  iodine,  the  galvanic  current,  etc.^ 

Neuritis  has  likewise  been  observed  in  pregnancy,  and  was  also 
then  allied  to  uncontrollable  vomiting.  Both  lower  limbs  and  the 
back  were  affected.  There  were  hypergesthesia  of  the  special  senses 
and  irregular  action  of  the  diaphragm.  The  case  had  a  fatal  issue,  and 
the  autopsy  revealed  degeneration  of  nearly  all  the  nerves  of  the  body, 
especially  the  phrenic  nerve. 

§  3.  Tetanus  and  Tetanoid  Contractions. — When  the  author 
published  his  investigation  about  these  conditions,^  which  had  the 
honor  of  being  translated  in  full  in  the  Archives  Gen^rales  de  3Iedecine 
of  Paris,  this  disease  was  hardly  mentioned  in  text-books  on  obstetrics. 
I  collected  fifty-seven  cases,  but  a  later  investigator  has  brought  the 
material  up  to  one  hundred  and  six  cases,  and  of  late  years  reports 
have  increased  in  number. 

In  America  and  Europe  puerperal  tetanus  is  a  very  rare  disease, 
while  it  is  quite  common  in  India,  not  only  as  compared  with  its 
appearance  in  other  countries,  but  also  with  tetanus  from  other  causes 
in  the  same  country. 

Etiology. — We  now  know  that  the  real  morbific  agent  is  the  tetanus 
bacillus,  a  microbe  which  produces  a  kind  of  poison  much  like  strych- 
nine, and  wliich  has  been  found  in  the  cavity  of  the  uterus  of  several 

^  For  further  particulars  see  Garrigues,  Diseases  of  Women,  lliinl  cd. ,  p.  699. 
^  Garrigues,    "Obstetrical  Tetanus   and   Tetanoid  Contractions."   Anier.  Jour. 
Obstetrics,  Oct.,  1882. 


792  ABNORMAL   PUERPERY. 

patients  affected  with  puerperal  tetanus.  This  bacillus  may  be  carried 
from  one  patient  to  another  on  the  hands  of  the  physician,  but  more 
frequently  it  is  brought  in  on  dressing  material  or  in  water  used  for 
injections ;  but,  since  puerperal  tetanus  is  such  a  rare  disease,  and  on 
the  other  hand  tetanus  of  the  new-born  child  is  so  common,  there 
must  be  other  factors  which  play  a  role  in  the  production  of  the 
disease. 

Besides  the  already  mentioned  influence  of  a  hot  climate,  other 
predisposing  or  concomitant  causes  deserve  attention.  Thus,  the  negro 
race  is  much  more  liable  to  this  infection  than  the  white  race.  The 
disease  is  more  common  in  the  wet  season.  It  appears  much  more 
frequently  in  country  practice  than  in  cities  ;  and  at  a  time  when  anti- 
septic midwifery  was  unknown  or  in  its  infancy,  and  when  epidemics- 
of  "  puerperal  fever"  raged  in  lying-in  hospitals,  tetanus  was  hardly 
ever  seen  in  these  institutions. 

Advanced  age,  primiparity,  and  mental  excitement  have  some  in- 
fluence, and  hemorrhage  is  a  most  important  factor.  Prolonged  lacta- 
tion has  a  similar  effect.  In  several  cases  the  patients  have  risen  toO' 
early  and  exposed  themselves  to  wet  and  cold,  by  which  perspiration 
and  lochial  discharge  were  suddenly  checked. 

The  disease  is  much  oftener  allied  with  abortions  than  with  de- 
liveries at  term.  Operations,  especially  artificial  abortion,  artificial 
detachment  of  the  placenta,  and  version, — in  other  words,  operations 
in  which  a  hand  or  a  fmger  is  introduced  into  the  uterus, — favor  the 
outbreak.  Retention  of  the  placenta  or  parts  of  it  has  also  been 
found  in  several  cases. 

Symptoms. — The  disease  may  arise  any  time  during  the  first  month 
after  confinement,  but  generally  it  does  so  before  the  sixth  day.  In 
rare  cases  it  has  appeared  in  pregnancy  or  during  labor.  It  does  not 
in  any  way  differ  from  tetanus  produced  under  other  circumstances. 
It  is  characterized  by  tonic  contractions  of  the  voluntary  muscles, 
intercurrent  convulsions,  and  increased  reflex  irritability.  It  begins 
always  at  or  near  the  neck.  Sometimes  lockjaw — inability  to  open 
the  mouth  on  account  of  contraction  of  the  masseters — is  the  first 
symptom  noticed.  In  other  cases  difficulty  in  swallowing,  produced 
by  the  constriction  of  the  pharyngeal  muscles,  in  others  again  stiffness 
of  the  neck  opens  the  scene.  The  mouth  is  drawn  so  as  to  simulate 
a  smile,  so-called  risus  sardonicus,  contrasting  with  the  corrugated 
eyebrows  and  the  general  facial  expression  of  anxiety  and  suffering. 
During  a  paroxysm  the  eyes  are  drawn  back  in  their  sockets  and 
remain  wide  open.  The  pupils  become  much  contracted  and  do  not 
react  to  light.  Whether  the  face  becomes  pale  or  flushed  and  swollen 
depends  upon  the  condition  obtaining  in  the  larynx. 

Soon  the  muscular  contractions  extend  from  the  head  and  neck  to 


-DISEASES   OF   THE   NERVOUS   SYSTEM.  793 

the  trunk  and  the  extremities.  As  a  rule,  the  muscles  of  the  poste- 
rior surface  of  the  body  are  more  contracted  than  those  in  front,  so 
that  under  a  paroxysm  the  patient  rests  only  on  the  head  and  the 
heels.     Emprosthotonus  is  much  rarer. 

Generally  the  contractions  of  the  muscles  are  painful,  and  some- 
times there  is  felt  a  particularly  severe  pain  in  the  epigastric  region, 
which  probably  is  due  to  tetanic  contractions  of  the  diaphragm. 
In  consequence  of  the  pain  the  patient  commonly  becomes  the 
victim  of  restlessness  and  insomnia,  but  the  intelligence  remains 
unimpaired. 

The  temperature  in  most  cases  rises,  and  may  even  reach  107.6^ 
F.  There  is  especially  an  elevation  towards  evening.  Exceptionally 
the  temperature  is  subnormal.  The  sweat  secretion  augments.  The 
pulse  is  weak  and  rapid. 

Sometimes  micturition  is  difficult  and  painful,  or  the  bladder 
empties  itself  involuntarily.  The  bowels  are  generally  constipated, 
but  sometimes  involuntary  evacuations  occur.  As  a  rule,  the  urine 
does  not  contain  albumin. 

Prognosis. — Puerperal  tetanus  may  last  from  a  few  hours  to  a 
month,  but  rarely  over  eight  days.  It  ends  nearly  always  fatally  (of 
106  patients  only  12  survived).  After  abortion  the  mortality  is  still 
greater  than  after  labor  at  term.  The  cause  of  death  is  asphyxia  or 
exhaustion  from  pain  and  lack  of  sleep. 

Diagnosis. — Tetanus  is  easily  distinguished  from  eclampsia.,  the 
only  common  feature  being  convulsions.  Eclampsia  is  commonly 
combined  with  albuminuria,  and  there  are,  as  a  rule,  casts  in  the 
urine.  In  tetanus,  with  rare  exceptions,  the  urine  does  not  contain 
either  casts  or  albumin.  Eclampsia  is  usually  ushered  in  by  forebod- 
ings, such  as  cardialgia,  headache,  vertigo,  oedema  of  face  and  hands, 
hght  twitchings  of  the  facial  muscles  ;  tetanus  comes  on  suddenly.  In 
eclampsia  the  convulsions  are  clonic,  or  alternately  clonic  and  tonic ; 
in  tetanus  they  are  tonic  with  exacerbations.  During  an  eclamptic 
attack  the  patient  is  unconscious,  and  the  convulsions  are  followed  by 
deep  coma ;  in  tetanus  the  intellect  is  perfectly  preserved  throughout 
the  course  of  the  disease.  The  tetanic  convulsions  may  be  brought 
on  by  touch,  noise,  or  similar  sensory  impressions ;  nothing  of  the 
kind  is  the  case  with  eclampsia.  In  the  latter  disease  the  patient,  as 
a  rule,  feels  much  less  pain.  The  temperature  is  not  so  high.  The 
pupils  are  dilated ;  in  tetanus  they  are  contracted. 

The  diagnosis  from  epilepsy  cannot  present  much  difficulty  either. 
The  patient's  history  reveals  that  she  is  accustomed  to  such  seizures. 
Often  an  aura  is  present.  The  contractions  may  at  first  be  tonic,  but 
soon  they  assume  the  clonic  type.  They  are  accompanied  by  loss  of 
consciousness.     The  temperature  is  normal  or  scarcely  raised.     The 


794  ABNORMAL    PUERPERY. 

attack  lasts  at  most  a  quarter  of  an  hour.    There  are  long  intervals 
between  the  attacks. 

The  differentiation  from  hysteria  may  be  more  difficult.  Indeed, 
all  the  muscles  of  the  body  may  become  tetanically  contracted  by 
hysterical  spasms.  Commonly  the  history  will  disclose  that  the 
patient  is  subject  to  similar  attacks.  There  are  generally  fits  of  laugh- 
ing or  crying  or  tossing  about  in  the  bed,  or  some  display  of  an  ego- 
tistical interest  in  the  morbid  phenomena,  or  sudden  changes  from 
one  state  to  another,  which  give  the  disease  a  peculiar  stamp  and 
form  a  picture  essentially  different  from  that  of  the  poor  being  racked 
by  tetanus  with  its  constant  contractions,  only  interrupted  by  parox- 
ysms in  which  they  increase  in  intensity  and  spread  to  points  hereto- 
fore at  rest. 

Tetanus  must  also  be  differentiated  from  symptomatio  tonic  convul- 
sions. Local  affections  of  the  brain  or  cord  may  be  distinguished  by 
the  history,  want  of  paroxysms  induced  by  reflex  action,  and  the 
absence  of  periodical  remissions.  In  affections  of  the  nerve-centres 
the  tetanic  contraction  is  limited  to  the  upper  or  lower  extremity, 
and  it  is  soon  followed  by  paralysis  of  the  same  parts. 

Cases  of  general  excitement  of  the  whole  nervous  system  are 
characterized  by  a  different  history,  a  marked  contrast  between  the 
most  severe  paroxysms  and  complete  relaxation,  and  an  entirely  dif- 
ferent course. 

Tetanic  contractions  may  occur  in  diseases  in  which  the  blood  is 
in  an  abnormal  condition,  such  as  smallpox,  scarlet  fever,  typhoid 
fever,  pyaemia,  ureemia,  etc.  Here  the  tetanic  contractions  appear  at 
irregular  intervals.  If  they  are  due  to  malaria,  they  are  intermittent. 
If  tetanus  is  limited  to  certain  groups  of  muscles,  it  might  be  con- 
founded with  tetanic  contraction  due  to  local  irritation  of  certain 
nerves,  but  by  following  the  course  of  the  disease  its  nature  will  soon 
become  clear. 

Pathology. — Autopsies  show  hypersemia  and  a  diffuse  growth  of 
connective  tissue  in  the  brain,  the  spinal  marrow,  and  the  meninges. 

Treatment. — With  our  present  knowledge  of  the  true  nature  of  the 
disease,  our  treatment  must  first  of  all  be  directed  against  the 
invasion  of  tetanus  bacilli.  As  to  prophylaxis,  we  cannot  do  more 
than  follow  the  general  rules  for  aseptic  and  antiseptic  midwifery. 
When  the  disease  breaks  out,  tetanus-antitoxin  should  be  injected 
hypodermically  or  into  the  spinal  canal  between  the  first  and  second 
lumbar  vertebra  (compare  p.  205),  or  perhaps  even  right  into  the 
brain  after  trephining.  It  is  also  rational  to  try  to  clean  out  the 
uterine  cavity  by  copious  antiseptic  injections.  The  mortality  being 
so  enormous,  Ave  may  in  the  beginning  of  the  disease  try  by  vaginal 
hysterectomy  to  remove  the  focus  of  infection. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  795 

At  the  same  time  the  terrible  sufferings  of  the  patient  call  for  alle- 
Tiation.  Opium  seems  to  have  done  little  or  no  good.  Chloroform 
and  ether  have  sometimes  been  useful,  but  in  other  cases  increased 
the  pain.  Chloral,  in  doses  of  fifteen  grains  by  the  mouth  or  from 
half  a  drachm  to  a  drachm  by  the  rectum,  has  given  better  results 
than  most  drugs.  Nitrite  of  amyl  has  also  antispasmodic  effect  and 
is  easily  given  in  the  dose  of  two  or  three  drops  by  inhalation.  Bro- 
mides may  also  contribute  to  the  patient's  comfort. 

On  account  of  the  hyperaemia  of  the  central  nervous  system,  ice- 
bags  on  the  head  and  along  the  spine  and  cold  baths  are  indicated. 
Warm  baths  may  be  used  to  tranquillize  the  nervous  system.  A  tur- 
pentine enema  may  act  as  a  useful  counter-irritant.  At  a  later  stage 
of  the  disease  iodides  may  be  given  in  order  to  reduce  the  new-formed 
connective  tissue. 

Tetanoid  Contractions. — Besides  true  tetanus,  tetanoid  contrac- 
tions are  found  in  connection  with  pregnancy  and  lactation.  They 
differ  from  true  tetanus  by  being  intermittent  or  having  an  hysteric 
character,  but  they  may  be  grave  enough  to  cause  the  patient's  death. 

Tetany  is  specifically  intermittent  and  occurs  only  during  preg- 
nancy or  in  consequence  of  lactation  (see  p.  323). 

§  4.  Eclampsia. — We  have  said  above  that  eclampsia,  if  it  breaks 
out  during  labor,  may  continue  for  several  days  in  the  puerperium.  It 
may  also  begin  during  this  period  and  then  generally  within  a  few  days 
after  delivery.  As  to  the  description  of  the  disease  and  its  treatment 
the  reader  is  referred  to  what  has  been  said  above  (pp.  325-333). 

§  5.  Insanity. — Since  the  time  of  Hippocrates  it  has  been  a  gen- 
eral belief  that  pregnancy,  parturition,  and  lactation  are  apt  to  produce 
mental  disease.  That  psychoses  are  common  in  one  of  these  conditions 
related  to  the  propagation  of  mankind  is  irrefutable,  but  in  order  not 
to  lay  too  much  weight  on  them  as  etiological  factors  in  the  production 
of  insanity  we  must  remember  that  the  whole  cycle  of  pregnancy,  par- 
turition, and  lactation  takes  from  a  year  and  a  half  to  two  years, 
and  then  ordinarily  begins  anew.  Consequently  a  very  large  number 
of  women  between  twenty  and  forty  years  of  age  are  in  one  of  these 
conditions,  and  it  could  therefore  hardly  be  expected  that  we  should 
not  find  a  correspondingly  great  number  of  cases  of  insanity  beginning 
in  women  in  these  conditions. 

If  child-bearing  had  a  very  marked  effect  on  the  production  of 
insanity,  there  would  be  a  much  larger  number  of  insane  women 
than  insane  men  ;  but  the  reports  of  alienists  show  that  there  is  little 
difference  in  regard  to  frequency  of  insanity  among  the  two  sexes, 
with  a  slight  preponderance  on  the  male  side.  This  is  accounted  for 
by  the  greater  frequency  of  alcoholism  and  syphilis  in  men.  But 
these  two  diseases  could  not  possibly  tip  the  scales  to  the  male  side 


796  ABNORMAL    PUERPERY. 

if  the  physiological  process  of  child-bearing  in  itself  were  so  powerful 
an  element  in  the  production  of  insanity  as  it  generally  has  been 
thought  to  be. 

Nevertheless  there  are  many  features  of  the  child-bearing  pro- 
cess which  may  make  the  patient  fall  a  victim  to  mental  disease  or 
may  favor  an  outbreak  of  insanity  in  a  person  with  hereditary  disposi- 
tion in  this  direction.  During  pregnancy  the  chemical  composition  of 
the  blood  changes,  and  the  nervous  system  becomes  more  sensitive. 
Parturition  is  accompanied  by  great  pain,  severe  congestion  of  the 
brain,  and  often  considerable  loss  of  blood,  either  before,  during,  or 
after  labor.  Many  women,  especiahy  among  those  who  have  become 
impregnated  out  of  wedlock  or  who  are  living  in  poverty,  are  apt  to 
undergo  great  emotions  from  shame,  contrition,  and  fear  for  the  future. 

There  is  no  specific  form  of  puerperal  insanity  that  can  be  recog- 
nized by  its  symptoms,  such  as  alcoholism  or  epilepsy.  The  chnical 
aspect  of  the  disease  is  the  same  as  when  it  occurs  outside  of  preg- 
nancy and  the  puerperal  state. 

From  an  etiological  stand-point  we  may  distinguish  idiopathic,  in- 
fectious^ and  toxic  insanity. 

Idiopathic  insanity  may  be  due  to  hereditary  disposition  or  any  of 
the  weakening  factors  mentioned, — loss  of  blood,  pain,  or  emotions. 
It  is  much  more  frequent  in  primiparae  than  among  those  who  have 
had  children  before.  It  begins  often  during  pregnancy  as  mere  sad- 
ness, which  develops  into  melancholia  with  tendency  to  suicide.  Dur- 
ing parturition  a  psychical  epilepsy  may  break  out.  The  patient  sud- 
denly becomes  very  excited.  Her  face  is  flushed,  the  eyes  are  staring, 
her  actions  are  impulsive  and  incoordinated.  She  may  attack  her 
friends  or  kill  her  child.  This  period  of  excitement  may  last  for  one 
or  more  hours,  after  which  the  patient  falls  asleep  as  after  an  epileptic 
attack,  and  when  she  awakes  there  is  complete  amnesia  in  regard  to 
all  that  has  happened  during  the  stage  of  agitation.  In  some  cases  of 
this  kind  the  patient's  previous  history  proves  that  she  has  been  suf- 
fering from  true  somatic  epileptic  attacks  at  an  earlier  period.  This 
form  has,  of  course,  great  medicolegal  interest,  since  the  culpability 
for  the  acts  committed  by  the  patient  during  the  attack  may  be  claimed 
or  denied. 

Excessive  loss  of  blood  may  produce  acute  delirium  with  an 
asthenic  type,  like  that  caused  by  inanition.  It  may  end  in  recovery 
after  a  short  time,  or  lead  to  death  or  a  secondary  psychosis. 

Infectious  insanity  is  a  result  of  puerperal  infection.  It  may  follow 
after  local  inflammatory  conditions  in  the  genitals,  such  as  colpitis, 
endometritis,  or  salpingo-oophoritis,  as  well  as  after  serious  general 
sepsis,  especially  encephalitis  or  meningitis.  Sometimes  it  is  due  to 
embolism  from  phlebothrombosis  or  from  endocarditis. 


DISEASES    OF   THE   NERVOUS   SYSTEM.  797 

The  attack  comes  generally  from  four  to  ten  days  after  delivery. 
There  is  no  prodromal  stage  or  a  very  short  one  of  mental  depres- 
sion. In  most  cases  the  patient  has  fever  due  to  the  inflammation,  but 
the  attack  may  also  come  with  normal  temperature.  From  a  dull  and 
apathetic  condition  the  patient  suddenly  passes  into  a  state  of  restless- 
ness and  agitation.  Hallucinations  of  one  or  more  senses  are  always 
present.  There  is  incoherence  of  thought  and  action.  The  entire 
list  of  psychosensory  and  psychomotor  symptoms  is  apt  to  occur  with- 
out order  or  system. 

The  prognosis  depends  largely  on  the  patient's  physical  condition. 
The  disease  may  end  fatally  or  in  recovery  within  a  short  time,  and  the 
mortality  is  considerable  ;  or  it  may  lead  to  ordinary  melancholia  or 
mania,  which  may  last  for  several  months,  and  which  also  may  end 
in  recovery  or  in  final  dementia. 

Toxic  insanity  is  due  to  the  presence  of  a  poison  in  the  blood, 
especially  to  uraemia,  which  may  be  allied  to  eclampsia  or  not.  Im- 
mediately or  a  day  or  two  after  the  patient  awakes  from  the  sopor  fol- 
lowing the  eclamptic  attack,  her  mental  faculties  are  unbalanced.  She 
has  no  fever,  but  suffers  from  hallucinations,  some  restlessness,  and  a 
tendency  to  melancholy.  This  condition  lasts  only  from  one  to  three 
days  and  always  ends  in  recovery. 

Lactation  as  such  plays  no  role  in  the  production  of  insanity.  The 
greater  tendency  to  nervous  and  mental  disease  found  during  the  first 
few  months  after  delivery  finds  its  natural  explanation  in  the  other 
causative  elements  we  have  mentioned  above.  The  psychoses  ob- 
served at  this  time  have  nothing  specific  in  their  clinical  features. 
They  are  the  same  as  might  occur  in  any  other  woman  at  any  other 
time.  It  is  unlikely  that  the  milk  has  any  deleterious  effect  on  the 
child,  but  since  lactation  is  a  drain  on  the  mother's  strength,  it  should 
be  discontinued. 

Treatment. — A  question  of  paramount  practical  importance  that 
presents  itself  to  the  obstetrician  is  whether  in  a  case  of  insanity 
developed  during  pregnancy  the  latter  shall  be  allowed  to  go  on  or 
shall  be  interrupted.  Since  nowadays  less  influence  on  the  produc- 
tion of  insanity  is  attributed  to  the  pregnant  condition  than  formerly, 
some  think  that  the  presence  of  pregnancy  in  itself  is  not  sufficient  to 
warrant  the  induction  of  artificial  abortion.  But  even  these  approve 
of  it  when  the  patient  loses  strength  and  flesh,  or  if  she  must  be 
forcibly  restrained,  or  if  it  is  necessary  to  feed  her  with  the  stomach- 
pump.  Personally  I  do  not  share  their  opposition  to  recourse  being 
had  to  abortion.  It  appears  to  me  that,  even  apart  from  the  question 
whether  or  not  anything  is  to  be  gained  in  regard  to  the  curability  of 
the  mother's  insanity  by  interrupting  her  pregnancy,  it  is  better  to  do 
so  in  the  interest  of  the  cliild  and  society.     Knowing  how  hereditary 


798  ABNORMAL   PUERPERY. 

a  disease  insanity  is,  it  is  humane  not  to  expose  the  child  to  be  born 
with  such  a  burden,  and  it  is  justifiable  to  spare  the  human  race  from 
an  addition  to  its  membership  of  such  doubtful  value. 

During  labor  the  obstetrician  will  watch  the  patient  and  restrain 
her  from  doing  any  harm  to  herself  or  others,  especially  her  child. 
After  labor  he  should  as  soon  as  feasible  place  the  woman  in  an 
asylum,  where  she  can  be  under  the  care  of  physicians  with  special 
training  in  the  treatment  of  mental  disease.  But  before  this  can  be 
done  there  are  duties  for  the  obstetrician  to  perform  towards  the  un- 
fortunate person.  If  there  has  been  great  loss  of  blood,  subcutaneous 
or  intravenous  injection  of  normal  salt  solution  is  indicated.  It  is, 
furthermore,  of  the  greatest  importance  to  feed  the  patient.  In  this 
direction  something  may  be  obtained  by  rectal  alimentation,  but  it  is 
not  sufficient  under  the  given  circumstance.  If  the  patient  refuses 
to  take  nourishment,  she  must,  therefore,  be  methodically  fed  by  the 
stomach-pump. 

If  the  insanity  is  due  to  infection,  the  obstetrician  will  have  to  treat 
this  as  he  would  do  under  ordinary  circumstances  ;  but  at  the  same 
time  he  should  pay  special  attention  to  the  patient's  nervous  system. 
Her  excitement  may  perhaps  be  soothed  by  a  wet  pack  or  a  warm 
bath.  If  she  is  feverish,  ice-bags  applied  to  her  head  and  spine  or 
sponging  with  alcohol  and  cold  water  may  be  useful.  Psychosensory 
irritation  calls  for  opiates.  The  psychomotory  is  quieted  by  hydro- 
bromate  of  hyoscine  (gr.  y^o— 0-6  milligramme— hypodermically  or 
gr.  Jq — 1.2  milligrammes — by  the  mouth). 

In  cerebral  congestion  ergotine  is  sometimes  valuable. 

In  the  restless  form  it  is  of  great  importance  to  produce  sleep,  for 
which  unusually  large  doses  of  hypnotics  may  be  required.  Trional 
or  sulphonal  may  be  given  in  doses  of  gr.  xxx  (2  grammes),  paralde- 
hyde in  doses  of  ^ii  (8  grammes)  or  even  ^iiss  (10  grammes). 


CHAPTER   VIIL 

ERUPTIVE   FEVERS. 


Scarlet  fever  is  a  rather  rare  complication  of  childbirth.  Some- 
times the  exposure  seems  to  have  taken  place  at  a  comparatively 
remote  date,  and  it  makes  the  impression  as  if  the  infection  had  been 
kept  back  but  was  furthered  by  the  occurrence  of  childbirth  with  its 
inevitable  wounds  in  the  genital  canal,  through  which  the  infecting 
agent  probably  gains  access  to  the  interior  of  the  body.  This  belief 
is  based  upon  the  fact  that  often  the  redness  first  appears  on  the  vulva, 
that  the  vagina  frequently  shows  diphtheritic  infiltration,  that  there 


ERUPTIVE   FEVERS.  799 

commonly  is  found  pelvic  inflammation,  and  that,  on  the  other  hand, 
the  throat,  as  a  rule,  is  much  less  affected  than  when  the  disease  is 
acquired  in  the  common  way,  which  probably  is  by  inhalation. 

It  has  also  been  noticed  that  the  incubation  is  unusually  short  in 
puerperal  scarlatina.  Whereas  ordinarily  there  pass  from  five  to  seven 
days  between  the  exposure  and  the  outbreak  of  the  disease,  puerperal 
scarlatina  generally  appears  in  one  or  two  days.  The  redness  shows 
soon,  is  unusually  dark,  and  spreads  rapidly  over  the  whole  body. 

The  germs  of  the  disease,  like  those  of  puerperal  infection,  may 
be  brought  on  the  hands  of  physicians  or  nurses,  on  dressing  material, 
or  through  the  air.  Puerperag  do  not  seem  to  be  particularly  apt  to 
catch  the  disease,  otherwise  it  would  be  more  commonly  observed  in 
them  ;  and  if  a  case  appears  in  a  lying-in  hospital  no  great  difficulty  is 
experienced  in  preventing  or  limiting  its  spread. 

Prognosis. — Scarlet  fever  is  a  serious  complication  of  the  puerpery. 
The  lochial  discharge  and  milk  secretion  often  stop.  There  is  a  ten- 
dency to  hemorrhage.  The  convalescence  is  tedious  and  the  mortality 
considerable. 

Diagnosis. — Puerperal  infection  can,  as  we  have  seen  above  (p. 
718),  give  rise  to  a  rash  which  resembles  that  of  scarlet  fever,  and  if 
the  patient  dies  soon  the  diagnosis  may  be  doubtful.  Otherwise  we 
usually  have  no  great  difficulty  in  making  the  diagnosis,  in  which  we 
are  guided  by  the  following  points.  The  history  of  the  case  may  bear 
evidence  of  exposure  to  infection.  The  peculiar  uniform  redness  is 
diffused  over  the  whole  body.  A  similar  color  is  found  in  the  throat. 
The  tongue  looks  like  a  strawberry.  There  are  frequently  diphtheritic 
exudations  in  the  throat  or  in  the  vagina.  The  eruption  is  followed 
by  a  wide-spread  and  protracted,  often  repeated,  desquamation.  The 
kidneys  often  become  inflamed,  the  urine  containing  albumin  and  casts. 
If  the  child  or  another  person  who  approaches  the  patient  became 
similarly  affected,  it  would  be  strong  evidence  in  favor  of  the  patient's 
ailment  being  scarlet  fever. 

Treatment. — The  patient  should  at  once  be  isolated,  and,  since 
the  child  is  apt  to  catch  the  disease,  nursing  should  be  discontinued. 
Otherwise  the  case  should  be  treated  according  to  general  rules  for 
both  the  puerperal  condition  and  the  scarlet  fever. 

Measles  and  smallpox  are  rare  in  puerperal  women,  and  do  not 
offer  any  peculiarities,  except  that  like  all  eruptive  fevers  they  have 
a  tendency  to  cause  hemorrhage. 

Erysipelas  is  not  so  very  rare,  and  it  is  a  dangerous  complication 
of  the  lying-in  period.  It  ordinarily  starts  from  the  genitals  or  the 
breasts  (p.  765). 

The  identity  of  the  streptococcus  found  in  puerperal  fever  and 
that  of  erysipelas  has  been  mentioned  above  (p.  691),  and  likewise 


800  ABNORMAL   PUERPERY. 

the  similarity  between  the  far-spreading  celluhtis  of  puerperal  infection 
and  the  inflammation  extending  all  over  the  skin  in  erysipelas  (p.  703). 

Typhoid  fever  is  not  rare  either,  and  has  an  unfavorable  influence 
on  the  puerperal  state. 

In  all  eruptive  fevers  nursing  should  be  discontinued. 


CHAPTER   IX. 

OTHER   FEVERS. 


Malarial  Fever. — True  malaria  may  attack  a  woman  in  the  puer- 
peral state,  and  there  is  even  greater  susceptibility  to  the  malarial 
poison  in  this  condition  than  outside  of  it.  But  there  is  no  doubt  that 
many  practitioners  lay  the  blame  for  illness  occurring  after  childbirth 
on  malarial  infection,  while  in  reality  it  is  due  to  puerperal  infection 
and  sepsis.  From  a  practical  stand-point  it  is  much  safer,  when  there 
is  any  doubt,  to  treat  the  case  as  puerperal.  For  the  diagnosis  of 
malaria  the  presence  of  the  plasmodium  in  the  blood  should  be 
demonstrated.  If  the  intermittent  type  is  pronounced,  that  is  an 
important  diagnostic  point ;  but  often  the  fever  is  continuous  or  more 
remittent. 

Malaria,  like  the  eruptive  fevers,  is  apt  to  cause  hemorrhage,  and 
occasionally  the  disease  may  appear  in  its  most  serious  forms. 

During  the  attack  of  fever  the  milk  secretion  ceases  altogether, 
and  in  the  interval  it  is  diminished.  Whether  the  disease  can  be 
communicated  to  the  child  through  the  milk  is  an  unsettled  question. 

In  women  who  had  malaria  before  confinement,  it  is  apt  to  come 
again  after  the  birth  of  the  child,  in  most  cases  on  the  third  day. 

Unusually  large  doses  of  quinine  may  be  needed  to  check  the  fever. 
It  is  best  to  give  it  in  full  doses  of  fifteen  grains  or  more,  repeated,  if 
necessary,  three  times  a  day  or  oftener.  Since  it  does  not  pass  into 
the  milk,  it  is  safe  to  continue  lactation. 

A  moderate  fever  is  quite  frequently  due  to  constipation,  and 
vanishes  as  soon  as  the  bowels  are  moved.  In  many  cases  it  is  due 
to  sore  nipjjles  or  mastitis.  In  others  again  it  is  of  emotional  origin. 
Perfect  quiet  should  therefore  reign  in  the  lying-in  room,  and  the 
patient  should  be  carefully  guarded  against  all  unpleasant  or  violent 
impressions. 


PART   v.— NOTES   ON   DISEASES   OF   NEW-BORN 

CHILDREN. 


CHAPTER   I. 
DISEASES    OF   THE    NAVEL. 

The  navel,  offering  a  suppurating  sore,  often  becomes  a  starting- 
point  of  disease  in  the  new-born  child. 

§  1.  Umbilical  Fungus. — Ordinarily  the  granulating  surface  left 
where  the  cord  has  fallen  off  heals  within  two  weeks  after  the  birth 
of  the  child.  Sometimes,  however,  this  does  not  take  place,  and  it 
continues  to  secrete  a  purulent  fluid.  On  examination  a  small  mush- 
room-shaped granuloma — a  so-called  umbilical  fungus — is  found  to 
spring  from  the  site  of  the  umbilical  cord.  It  is  nearly  always  more 
or  less  pediculated,  and  sometimes  contains  remnants  of  the  omphalc- 
mesenteric  duct  in  the  shape  of  a  fme  canal  covered  inside  with  a 
single  layer  of  columnar  epithelium.  Sometimes  the  umbilical  vessels 
resist  decay  longer  than  the  surrounding  softer  tissue  of  the  stump  of 
the  cord,  forming  a  little  penis-like  protrusion.  This  little  growth 
goes  on  secreting  indefinitely,  but  the  cure  is  as  simple  as  it  is  effective. 
A  silk  thread  is  thrown  around  the  base  of  the  tumor  and  tightened. 
In  a  few  days  it  falls  off,  and  the  base  is  rapidly  covered  with  epidermis. 

The  umbilicus  may  also  continue  to  secrete  pus  without  the  forma- 
tion of  a  tumor — umbilical  ulcer.  It  should  be  cleaned  with  saturated 
solution  of  boric  acid  or  Thiersch's  solution  and  dressed  with  sali- 
cylic acid  or  benzoate  of  sodium  mixed  with  amylum  or  talcum  (from 
forty  to  twenty  parts). 

§  2.  Hemorrhage. — We  have  recommended  (p.  196)  to  tie  the  cord 
with  a  bow  and  reinspect  it  before  leaving  the  house  in  order  to  satisfy 
ourselves  that  there  is  no  oozing  through  the  umbilical  vessels.  But 
later  there  may  be  loss  of  blood  from  the  area  of  separation  between 
the  perishable  and  the  permanent  portions  of  the  stump.  This  is 
particularly  liable  to  happen  if  the  stump  is  cut  long  and  gets  dry,  or 
if  the  dressing  is  torn  off  without  soaking  it.  The  accident  has  most 
often  happened  in  children  affected  with  hereditary  syphilis. 

Perhaps  a  touch  with  a  stick  of  lunar  caustic,  a  20  to  50  per  cent, 
solution  of  ferripyrin,  or  the  application  of  the  dry  extract  of  supra- 
renal capsule  substance  may  suffice  to  stop  bleeding.  If  it  does  not, 
two  harelip-pins  should  be  passed  crosswise  through  the  umbilical 
cone  and  a  ligature  applied  around  them. 

ol  ,  801 


802  NOTES    ON    DISEASES    OF   NEW-BORN    CHILDREN. 

If  the  child  is  suffering  from  haemophilia,  congenital  syphihs,  gen- 
eral sepsis,  or  acute  fatty  degeneration,  even  this  mechanical  hsemostasis 
may  be  futile,  since  new  bleeding  starts  from  the  pinholes.  Sometimes 
plaster  of  Paris  has  proved  successful  and  in  other  cases  the  actual 
cautery.  Persalts  of  iron  should  be  avoided,  as  they  form  hard  scabs 
under  which  moisture  accumulates  and  gives  rise  to  sepsis. 

§3.  Umbilical  Arteritis.  —  Sometimes  the  umbilical  arteries  in 
their  course  between  the  bladder  and  the  umbilicus  remain  pervious, 
and  the  suppuration  extends  from  the  stump  through  these  vessels. 
By  pressure  along  the  arteries  up  towards  the  umbilicus  it  maybe  pos- 
sible to  press  out  a  little  pus.  The  surrounding  connective  tissue  of 
the  abdominal  wall  may  also  become  inflamed — omphalitis — forming  a 
subcutaneous  abscess  or  a  deep  one  which  lies  in  direct  contact  with 
the  peritoneum.  Such  abscesses  should  be  laid  freely  open  and 
dressed  with  the  above-mentioned  mild  antiseptic  solutions.  Carbolic 
acid,  bichloride  of  mercury,  and  iodoform  are  too  dangerous.  At  a 
later  stage,  bismuth,  oxide  of  zinc,  or  dermatol  may  be  used. 

§  4.  Umbilical  phlebitis  is  rarer  than  umbilical  arteritis,  but  also 
much  more  dangerous. 

All  these  umbilical  inflammations  are  due  to  the  entrance  of  strep- 
tococci and  staphylococci  from  the  umbilicus.  The  infection  may  take 
a  septic  or  a  pycemic  form.  In  the  former  there  is  a  general  dissolu- 
tion of  the  blood,  vomiting,  swelling  of  the  abdomen,  pain,  and  great 
sensitiveness,  due  to  peritonitis  which  rapidly  ends  in  death.  In  the 
pyaemic  form  the  prognosis  is  somewhat  better.  Thrombi  and  abscesses 
are  formed  in  different  parts  of  the  body,  but  after  they  have  been 
opened  and  have  healed,  the  child  may  ultimately  recover. 

§  5.  Gangrene.  —  In  bad  cases  of  umbilical  inflammation  the 
anterior  abdominal  wall  may  become  gangrenous.  Then  dead  tissue 
should  be  removed  with  knife  or  scissors,  the  wound  dressed  antisep- 
tically,  and  the  flagging  strength  increased  by  the  administration  of 
alcohol  (1  or  2  teaspoonfuls  of  whiskey  in  the  24  hours,  diluted  with 
eight  times  as  much  water  and  sweetened  with  sugar.) 


CHAPTER   II. 
PUERPERAL   INFECTION. 

Infection  does  not  always  start  from  the  navel.  As  we  have  seen 
above  (p.  694),  it  may  also  enter  through  sores  in  the  mouth  or 
accidental  wounds  ;  or  it  may  come  from  decomposed  liquor  amnii  or 
meconium  which  the  child  aspires  into  its  lungs  if  it  begins  to  breathe 
while  it  is  still  in  the  uterus ;  or  it  may  be  due  to  breathing  infected 


GONORRHGEAL   INFECTION.  803 

air.  It  may  even  be  acquired  from  tlie  mother  before  birtli,  microbes 
perforating  and  passing  through  the  normal  partition  between  the 
maternal  and  fetal  organisms. 

General  septicEemia  is  nearly  always  fatal.  We  may  often  prevent 
the  disease  by  following  the  rules  of  antisepsis.  The  child  should  be 
kept  clean.  The  navel  should  be  dressed  antiseptically.  The  room 
should  be  well  ventilated.  The  person  who  takes  care  of  the  mother 
and  child  during  the  lying-in  period  should  always  disinfect  her  hands 
before  manipulating  the  child,  and  should  attend  to  the  child  before 
touching  the  mother.  The  child  should  not  lie  in  the  same  bed  with 
the  mother. 

If  infection  takes  place  and  is  localized,  it  should  be  treated  by 
antiseptic  applications.  Abscesses  should  be  opened  and  dressed. 
The  only  internal  remedy  of  any  value  is  alcohol. 


CHAPTER   III. 
GONORRHEAL   INFECTION. 

§1.  Ophthalmia  Neonatorum.  —  Ophthalmia  of  the  new-born 
child,  or  ophthalmoblennon-hoea^  is  a  purulent  conjunctivitis  produced 
by  the  entrance  of  the  gonococcus  of  Neisser  into  the  conjunctival 
sac.  As  a  rule,  the  infection  takes  place  while  the  child  is  being  pressed 
through  the  vagina  and  vulva  of  the  mother ;  or,  after  delivery  of 
the  head,  if  it  hangs  down  into  the  collection  of  blood,  mucus,  and 
liquor  amnii  accumulated  upon  the  couch,  between  the  thighs  of  the 
mother ;  or,  if  the  child  dips  its  hands  into  this  unwholesome  lake  or 
against  the  maternal  genitals,  and  then  carries  them  to  its  eyes. 

The  infecting  agent  may  also  be  carried  from  one  patient  to  another 
by  doctors,  midwives,  or  nurses  ;  or  the  disease  may  be  acquired  in 
a  bath,  if  the  same  water  is  used  for  several  children. 

Much  more  rarely  the  child  already  has  the  diplococci  in  its  eyes 
when  it  leaves  its  mother's  body.  This  is  possible  only  in  cases  in 
which  the  bag  of  waters  ruptured  several  days  before  delivery,  thus 
allowing  the  microbes  to  be  carried  into  the  uterus. 

The  incubation  lasts  two  or  three  days.  Then  the  eyes  begin  to 
swell,  and  a  serous  fluid  mixed  with  a  few  purulent  flocculi  distils 
from  the  slit  between  the  eyehds.  If  left  to  themselves,  in  another 
couple  of  days  the  swelling  becomes  so  great  that  the  child  cannot 
open  its  eyes ;  and  the  discharge  becomes  thick,  creamy,  greenish- 
yellow  pus.  Next,  the  cornea  becomes  opaque,  a  perforation  takes 
place,  and  the  eye  collapses  and  atrophies.  As  a  rule,  both  eyes 
become  affected. 


804  NOTES    ON   DISEASES    OF   NEW-BORN    CHILDREN. 

The  disease  used  to  be  very  common.  In  a  service  of  only  thirty- 
five  births  a  month  we  had  frequently  half  a  dozen  cases  of  ophthal- 
mia on  hand  in  Maternity  Hospital.  In  other  institutions  from  7  to 
12  per  cent,  of  the  children  were  thus  affected. 

If  neglected  the  disease  generally  ends  in  blindness.  According 
to  large  statistics,  from  one-third  to  two-thirds  of  the  inmates  of  insti- 
tutions for  the  blind  had  acquired  their  dreadful  calamity  from  this 
source. 

All  this  has  been  changed  since  Crede's  great  discovery  that  in 
silver  nitrate  we  have  an  almost  absolutely  sure  prophylactic  against 
gonorrhoeic  ophthalmia.  During  the  first  twelve  months  after  I  intro- 
duced this  treatment  in  Maternity  Hospital,  351  children  were  born 
alive.  All  had  the  silver  treatment,  and  not  a  single  one  got  inflam- 
mation of  the  eyes  in  a  service  full  of  women  from  the  very  lowest 
strata  of  the  city,  many  of  whom  doubtless  were  affected  with  old  or 
recent  gonorrhoea.  A  single  child,  through  the  negligence  of  an 
assistant,  was  not  treated,  was  attacked  by  ophthalmia,  and,  although 
put  under  the  care  of  able  physicians  in  the  eye  department,  lost  the 
sight  in  both  eyes.  This  has  made  such  a  deep  impression  on  me  that 
I  am  inclined  to  ascribe  the  rare  cases  that  yet  are  reported  not  to 
unreliability  of  the  remedy,  but  to  unfaithfulness  in  its  use.  Withal 
only  one-half  of  one  per  cent,  or  less  cases  are  nowadays  reported 
from  lying-in  hospitals. 

Others  have  recommended  bichloride  of  mercury  (1 :  2000),  or 
argonin  (5  per  cent.).  Protargol  (10  per  cent.)  used  in  the  same  way 
is  said  to  be  as  effective  as  nitrate  of  silver  and  less  irritating. 

The  diagnosis  offers  no  difficulty.  No  other  inflammation  of  the 
eyes  is  cliaracterized  by  sucli  an  enormous  swelling  and  such  profuse 
discharge  of  thick  pus.  Besides,  bacteriological  examination  shows 
the  presence  of  the  diplococous  in  the  interior  of  the  pus-cells. 

Treatment. — In  regard  to  prophylaxis  enough  has  been  said  in 
speaking  of  the  conduct  of  normal  labor  (p.  209).  Here  I  shall  only 
add  that  it  may  be  well  to  bandage  the  child's  eyes  immediately  after 
it  is  delivered  and  to  keep  the  head  away  from  the  pool  in  front 
of  the  maternal  genitals.  Of  still  greater  importance  is  it,  when 
only  one  eye  is  affected,  to  apply  a  monoculus  to  the  healthy  eye ; 
but  then  this  must  be  inspected  daily  and  taken  under  treatment  as 
soon  as  it  shows  signs  of  beginning  inflammation. 

The  curative  treatment  consists  in  ice,  boric  acid,  and  silver,  but  it 
is  so  troublesome  that  at  least  two  nurses  are  needed  to  treat  one 
child.  The  eyes  should  be  covered  with  small,  fine  ice-bags  (con- 
doms, which  may  be  obtained  from  rubber  manufacturers  under  the 
innocent  name  of  "  protectors  for  two  fingers").  This  is  much  easier 
than  to  place  pieces  of  lint  on  a  block  of  ice,  apply  them  to  the  eyes. 


GONORRHCEAL    INFECTION.  805 

and  change  them  as  often  as  they  become  warm,  which  is  almost  in- 
stantly. Every  hour,  day  and  night,  the  eyes  are  thoroughly  cleaned 
with  a  saturated  solution  of  boric  acid,  which  is  made  to  fall  in  a 
copious  stream  right  into  the  eye  by  spreading  the  eyelids  apart  and 
squeezing  in  front  of  the  eye  a  wad  of  absorbent  cotton  soaked  in  the 
solution.  The  third  measure  to  be  taken  is  the  use  of  strong  nitrate 
of  silver  solution  to  kill  the  gonococci.  For  this  purpose  the  same 
treatment  may  be  used  as  we  have  described  for  the  prevention  of  the 
disease.  A  drop  of  a  2  per  cent,  solution  should  be  dropped  into  the 
eye  and  moved  all  around.  Another,  and  perhaps  better,  way  is  once 
a  day  to  evert  the  eyelids  and  paint  the  inside  with  a  camel's-hair  brush 
dipped  in  a  10  per  cent,  solution  and  then  pour  salt  solution  over  them 
in  order  to  neutralize  the  redundant  silver  solution.  The  physician 
may  improvise  the  salt  solution  by  dissolving  half  a  teaspoonful  of 
table  salt  in  a  wineglassful  of  water.  A  teaspoonful  of  this  solution  is 
poured  over  each  eye. 

If  there  is  any  opacity  of  the  cornea,  the  iris  should  be  dilated  by 
dropping  three  or  four  times  a  day  a  solution  of  sulphate  of  atropine 
(1  :  150-200)  into  the  eyes.  If  an  ulcer  forms  on  the  cornea,  ice 
should  be  discontinued. 

When  the  violent  inflammation  has  subsided,  milder  astringent 
solutions,  such  as  silver  nitrate  (1  :  500-1000),  are  required. 

In  order  to  be  able  to  act  in  time,  it  is  absolutely  necessary  to 
see  the  cornea  every  day.  If  the  eyelids  are  very  swollen  and 
stiff  it  may  be  impossible  to  expose  the  bulb  with  the  fingers  alone. 
Under  such  circumstances  the  writer  has  found  Desmarre's  retrac- 
tors excellent  (Fig.  502.) 

Fig.  502. 


G.TIEMANN&CO 


Desmarre's  eyelid  retractors. 

The  result  of  the  treatment  is  so  doubtful  that,  whenever  possible, 
the  obstetrician  had  better,  in  his  own  interest  as  well  as  in  that  of  the 
patient,  turn  the  case  over  to  an  oculist. 

As  a  rule,  the.  friends  have  no  idea  of  the  nature  of  the  disease  or 
its  gravity.  The  wise  old  women  ascribe  it  to  a  cold,  and  a  favorite 
remedy  is  to  wash  the  eyes  with  the  mother's  milk.  If  the  physician 
does  not  see  the  child  after  its  birth,  he  should  leave  strict  orders  to 
send  for  him  immediately  if  its  eyes  become  inflamed. 


806  NOTES    ON   DISEASES    OF   NEW-BORN    CHILDREN. 

§  2.  Gonorrhoea!  Stomatitis. — The  gonococcus  may  find  its  way 
into  ttie  mouth  of  the  baby,  where  it  causes  a  wide-spread,  super- 
ficial, purulent  inflammation.  The  mucous  membrane  becomes 
intensely  red,  the  epithelium  is  affected  and  thrown  off,  but  the 
general  health  does  not  seem  to  suffer.  The  disease  ends  within  four 
or  five  weeks  in  recovery. 

Treatment. — The  mouth  should  be  swabbed  hourly  with  saturated 
solution  of  boric  acid,  and  painted  with  argenti  nitras  (gr.  i  to  gi — 6 
centigrammes  to  30  grammes)  three  times  a  day.  The  eyes  should 
be  closely  bandaged  and  carefully  watched,  lest  with  its  fingers  the 
child  bring  the  infecting  agent  to  them  from  its  mouth. 

§  3.  Gonorrhoea!  -<Sjdoeoco!pitis. — In  rare  cases  the  vulva  and 
vagina  of  new-born  girls  become  infected  with  the  gonococcus,  which 
produces  redness  and  purulent  discharge. 

Treatment. — A  soft-rubber  catheter  should  be  introduced  to  the 
fornix  vaginae  and  the  canal  irrigated  three  times  a  day  with  a  quart 
of  a  1 :  3000  solution  of  permanganate  of  potassium.  Other  remedies 
that  have  been  recommended  for  injection  are  corrosive  sublimate 
(1  :  5000)  and  nitrate  of  silver  (2  per  cent.). 


CHAPTER   IV. 

DISEASES   OF   THE   MOUTH. 

§  1.  Sprue. — Sprue,  tlwush.,  or  muguet  is  an  inflammation  of  the 
mouth  due  to  the  presence  of  a  fungus  called  o'idium  albicans,  or 
saccharomyces  albicans.  The  disease  appears  generally  in  the  first  or 
second  week  of  the  puerperium.  First  the  whole  mucous  membrane 
of  the  mouth  becomes  dark  red,  and  the  following  day  small,  round, 
white  elevated  spots  appear  on  the  inflamed  mucous  membrane. 
These  spread  and  coalesce,  forming  irregular  white  patches,  which 
adhere  more  or  less  firmly  to  the  flesh.  These  masses  are  composed 
of  oidium,  streptococci,  staphylococci,  fibrin,  curdled  milk,  epithelial 
cells,  and  detritus.  The  fungi  penetrate  deep  into  the  epithelium,  and, 
therefore,  resist  removal. 

The  same  fungus  is  found  in  the  chafed  surface  of  the  nates  of 
babies  and  often  in  the  vagina  of  women.  It  may  extend  into  the 
oesophagus  and  its  gonidia  are  found  in  the  gastro-intestinal  tract. 
More  rarely  it  invades  the  larynx.  It  has  even  caused  embolism  in  the 
brain  and  the  kidneys. 

Etiology. — The  disease  is  largely  due  to  lack  of  cleanliness.  Intes- 
tinal disturbances  favor  its  outbreak.  It  is  more  common  in  bottle-fed 
children  than  in  those  who  are  brought  up  on  breast-milk. 


DISEASES    OF   THE    MOUTH.  807 

Symptoms. — The  child  becomes  restless,  loses  appetite  and  weight ; 
sucking  is  painful ;  not  rarely  diarrhosa  sets  in.  Sometimes  the  child 
becomes  hoarse  and  may  develop  a  pneumonia. 

Prognosis. — If  taken  in  time  the  disease  is  easily  eradicated.  If 
neglected,  it  may  lead  to  diarrhoea,  exhaustion,  pneumonia,  and  death. 

Treatment. — The  preventive  treatment  consists  in  washing  out  the 

mouth  frequently,  especially  after  feeding,  Avith  a  soft  rag  and  plain 

cold  water.   '  When  the  white  spots  and  membranes  have  appeared, 

the  first  thing  to  do  is  to  rub  them  off  with  a  rag  dipped  in  an  acid 

wine  or  vinegar  and  then  to  paint  the  inside  of  the  mouth  after  each 

nursing  with 

B   Sodii  boratis,   J  i  (4  grammes)  ; 

Glycerini,  q.  s.  ad  ^i  (30  grammes). 

With  this  simple  treatment  I  have  always  seen  the  disease  disappear 
in  a  few  days.  Other  remedies  that  are  recommended  are  the  saturated 
solution  of  boric  acid,  permanganate  of  potassium  (from  one-half  to 
one  per  cent.),  or  nitrate  of  silver  (gr.  i  to  li — 6  centigrammes  to  30 
grammes),  all  used  for  swabbing  the  mouth  five  or  six  times  a  day. 
When  there  is  diarrhoea  the  following  formula  may  be  used  : 

R    Bismuthi  subnitrat.,  gr.  xv  (1  gramme)  ; 
Resorcin,  gr.  v  (30  centigrammes)  ; 
Glycerini,  ^ii  (8  grammes)  ; 
Aquae  dest. ,  q.  s.  ad  ,^ii  (60  grammes). — M. 
Sig. — Shake  well.     A  teaspoonful  every  two  hours. 

§  2.  Bednar's  Aphthae. — Bednar's  aphthae  are  flat,  circular  ulcers 
of  the  size  of  a  lentil,  generally  found  sym.metrically  on  both  sides 
of  the  hard  palate,  in  the  region  of  the  hamular  process  of  the 
sphenoid. 

The  mucous  membrane  is  here  only  half  as  thick  as  in  the  other 
parts  of  the  mouth.  The  pterygomaxillary  ligament  extends  from  the 
hamular  process  to  the  spine  in  which  the  internal  oblique  line  ends 
on  the  inside  of  the  lower  jaw,  and  it  stretches  this  part  of  the  mucous 
membrane  when  the  mouth  is  opened.  As  the  hamular  process  forms 
a  prominence,  the  back  of  the  tongue  is  pressed  with  particular  force 
against  it  when  the  child  nurses.  When  we  open  the  mouth  of  the 
child,  we  can  see  this  spot  blanch  and  become  anaemic.  All  this 
explains  why  these  two  spots  are  more  vulnerable  than  the  other 
parts  of  the  mouth. 

To  this  anatomical  and  physiological  i)rcdisposition  may  come 
traumatic  injury,  if  an  energetic  and  overzealous  nurse  sees  the 
anaemic  places  and  takes  them  for  sprue,  which  she  endeavors  to 
rub  off. 


808  NOTES    ON   DISEASES   OF   NEW-BORN    CHILDREN. 

Trifling  as  the  disease  is  in  itself,  it  acquires  importance  by  making 
sucking  painful,  and  thus  interfering  with  the  nutrition  of  the  child. 

The  ulcers  are  easily  cured  by  abstaining  from  injuring  them  and 
by  painting  them  with  the  above-mentioned  borax  solution.  Excep- 
tionally the  solutions  of  nitrate  of  silver  or  permanganate  of  potassium 
may  be  required. 

As  a  preventive  of  this  and  other  buccal  affections  it  is  well  to 
clean  the  mouth  by  giving  the  baby  a  few  teaspoonfuls  o'f  water  after 
each  meal. 

§  3.  Injury  to  Epithelial  Pearls.^ — In  the  mouths  of  nearly  all 
new-born  children — in  53  out  of  57  examined  by  me  for  the  purpose, 
or  93  per  cent. — are  found  so-called  epithelial  pearls.  These  are  small, 
white,  globular  tumors,  varying  in  size  from  that  of  a  pin-head  to  that 
of  a  millet-seed,  situated  in  the  raphe  of  the  palate,  preferably  at  the 
juncture  of  the  hard  and  the  soft  palate.  Sometimes  there  is  only 
one  such  pearl,  in  other  cases  from  two  to  five.  The  outer  surface  is 
almost  cartilaginous,  while  the  interior  is  filled  with  a  softer  mass. 
They  are  embedded  in  the  mucous  membrane  of  the  mouth,  the 
larger  reaching  from  the  epithehum,  in  which  they  may  even  pro- 
duce a  depression,  to  the  periosteum.  Most  of  them  have  a  cover- 
ing of  condensed  subepithelial  connective  tissue,  which  merges  into 
the  surrounding  tissue  without  any  distinct  line  of  demarcation.  Some- 
times, instead  of  the  round  prominence,  we  fnid  a  white  line  extend- 
ing as  much  as  half  an  inch  in  the  direction  of  the  raphe. 

Microscopical  examination  shows  that  the  Avhole  mass  is  composed 
of  epithelial  cells,  like  those  of  the  mucous  membrane  of  the  mouth. 
The  outer  layers  are  the  youngest,  as  appears  from  their  polyhedral 
form  and  the  presence  of  a  nucleus  ;  while  those  placed  near  the 
centre  are  flat  and  have  lost  their  nuclei,  just  as  the  case  is  with  the 
older,  superficial  epidermal  cells  compared  with  the  younger  of  the 
rete  Malpighii. 

Similar  formations  are  sometimes  found  on  the  free  edge  of  the 
alveolar  process,  especially  near  the  posterior  extremity. 

They  are  transient  growths,  which  in  healthy  children  soon  dis- 
appear. In  our  cases  the  pearls,  if  they  did  not  give  rise  to  stoma- 
titis, disappeared  within  one  or  two  weeks.  Several  nodules  were 
seen  to  coalesce  and  then  to  clear  up  and  gradually  disappear.  New 
ones  may  appear  after  the  birth  of  the  child.  In  badly  nourished 
children  the  involution  takes  more  time. 

These  little  growths  are  due  to  an  invagination  of  the  epithelium 
which   takes  place  where  the  two  halves  forming   the  palate  come 

^  Garrigues,  "  Stomatitis  due  to  Irritation  of  Epithelial  Pearls  in  the  Mouths  of 
New-Born  Children,"  Trans.  Amer.  Gyn.  Soc,  1892,  vol.  xvii.,  Medical  News, 
Oct.  1,  1892. 


GLANDULAR   SWELLINGS.  809 

together  and  unite  in  the  median  line  from  the  front  backward, 
and  likewise  on  the  alveolar  process  when  the  walls  of  the  dental 
furrow  grow  together  over  the  rudiments  of  the  future  teeth. 

If  these  pearls  are  injured  in  washing  the  mouth  with  a  coarse 
cloth  or  too  roughly,  they  become  inflamed  and  give  rise  to  superficial 
ulcers  covered  with  a  yellow  film  and  bounded  by  a  red  line.  The 
ulceration  extends  symmetrically  from  the  median  line  and  may 
occupy  the  whole  soft  palate.  Microscopical  examination  of  thfe 
yellow  substance  covering  the  ulcer  shows  only  pus-corpuscles  and  the 
usual  pyogenic  microbes.  The  general  health  of  the  children  remains 
undisturbed.  In  1892  we  had  quite  a  little  epidemic  in  Maternity 
Hospital  from  this  cause.  Of  27  babies  whose  mouths  had  been 
washed  immediately  after  their  birth  and  after  each  meal,  with  the 
velvety  side  of  a  piece  of  lint  soaked  in  a  saturated  solution  of 
boric  acid,  12  had  more  or  less  sore  mouths.  In  the  next  twenty- 
five  cases  we  desisted  from  all  washing  of  the  mouths,  so  that  nothing 
but  the  mother's  nipple  and  her  milk  entered.  Of  these  not  a  single 
one  was  affected. 

Diagnosis. — Epithelial  pearls  are  easily  recognized  by  their  definite 
locahzation  and  their  globular  shape.  The  ulcers  differ  from  Bednar's 
aphthce  by  their  locality.  Bednar's  ulcers  are  always  placed  laterally, 
and  usually  bilaterally,  whereas  those  caused  by  epithelial  pearls  are 
central.  Sprue  forms  small,  irregular,  less  elevated  white  spots,  which 
are  never  congenital,  may  be  found  anywhere,  and  have  no  sym- 
metrical development. 

The  ulcers  are  due  to  mechanical  injury  in  cleaning  the  mouth. 

The  treatment  consists  in  discontinuing  ablutions  of  the  mouth  and 
in  painting  with  borax  glycerin. 


CHAPTER   V. 
GLANDULAR    SWELLINGS. 

§  1.  Mastitis. — It  is  not  rare  that  the  mammary  glands  of  new- 
born children — male  as  well  as  female — become  inflamed.  The  little 
gland  then  forms  a  painful,  hard  protrusion,  out  of  which  can  be  pressed 
a  white  fluid  which  in  chemical  composition  and  microscopical  appear- 
ance is  like  colostrum.  As  a  rule,  the  swelling  subsides  in  a  few  days, 
but  it  may  also  suppurate,  and  the  pus  may  perforate  the  capsule  and 
spread  under  the  skin.  This  suppuration  is  accompanied  by  high 
fever  and  may  end  fatally. 

Treatment. — The  swollen  breast  should  be  covered  with  a  flax- 
seed-meal  poultice.  If  an  abscess  forms,  it  should  be  opened  with 
a  lancet,  washed  out,  and  dressed  with  a  saturated  solution  of  boric 


810  NOTES    ON    DISEASES    OF    NgW-BORN    CHILDREN. 

acid  or  Thiersch's  solution.  If  the  suppuration  has  spread  into  the 
connective  tissue,  it  may  be  necessary  to  make  several  incisions,  drain, 
and  remove  shreds  of  mortified  tissue.  At  the  same  time  the  little 
patient  should  have  a  teaspoonful  of  a  mixture  of  one  part  of  brandy 
or  whiskey  with  four  parts  of  water  every  one  or  two  hours  and  half 
a  grain  of  quinine  three  times  a  day. 

§  2.  Hypertrophy  of  the  Thymus  Gland. — The  thymus  gland  is  a 
temporary  organ  which  reaches  its  greatest  size  at  about  the  end  of  the 
second  year  of  life.  It  is  an  elongated  body  situated  partly  in  the 
thorax  and  partly  in  the  lower  region  of  the  neck.  It  lies  just  behind 
the  sternum  and  in  front  of  the  pericardium,  the  large  vessels,  and  the 
trachea.  It  reaches  from  the  lower  end  of  the  thyroid  body  to  the 
fourth-rib  cartilage.  At  birth  it  measures  about  two  inches  in  length, 
an  inch  and  a  half  in  width,  and  an  inch  and  a  quarter  in  thick- 
ness. It  is  composed  of  two  lateral  lobules.  It  is  a  vital  organ, 
and  its  role  is  probably  to  contribute  to  the  formation  of  blood. 

This  organ  may  be  hypertrophied  and  give  rise  to  serious  and 
even  fatal  dyspnoea  by  pressure  on  the  trachea,  the  pneumogastric, 
or  the  recurrent  nerve.  The  diagnosis  is  based  on  the  protrusion 
of  a  tumor  in  front  of  the  trachea  during  expiration.  A  cure  has 
been  effected  by  the  surgical  removal  of  portions  of  the  tumor. 


CHAPTER    VI. 

SKIN   DISEASES. 


After  having  been  suspended  in  a  serous  bath  of  uniform  tem- 
perature during  the  whole  duration  of  pregnancy,  the  new-born  child 
comes  in  contact  with  air,  with  water,  with  clothes,  and  with  alvine 
and  vesical  evacuations.  No  wonder,  then,  that  its  skin  easily  be- 
comes inflamed. 

§  1.  Erythema  is  very  common.  As  a  rule,  it  is  accompanied 
by  desquamation  of  the  epidermis — intertrigo.  The  buttocks,  part 
of  the  posterior  surfaces  of  the  thighs,  the  external  genitals,  and  the 
genitofemoral  and  inguinal  furrows  become  chafed,  and  show  large, 
red  areas  deprived  of  epidermis. 

The  chief  cause  is  lack  of  cleanliness  or  rough  handling. 

A  similar  condition  on  a  smaller  scale  is  sometimes  found  in  the 
armpits  or  the  furrows  of  the  neck,  where  it  probably  is  due  to 
perspiration.  It  is  especially  found  in  fat  children.  Intertrigo  may 
produce  diarrhoea,  and,  on  the  other  hand,  it  gets  worse  from  the 
acrid  intestinal  discharge. 

The  dermatitis  causes  pain  and  deprives  the  child  of  sleep. 

As  to  treatment,  the  first  thing  required  is  scrupulous  cleanliness. 


SKIN    DISEASES.  811 

The  child  should  not  be  allowed  to  lie  in  its  urine  and  faeces,  as  is 
often  the  case  among  the  lower  classes,  but  should  be  washed  with 
a  soft  sponge  and  lukewarm  water  after  every  evacuation.  The  skin 
should  not  be  rubbed  dry,  but  absorbent  cotton  or  soft  old  linen 
should  be  pressed  against  it  to  soak  up  the  moisture.  If  the  derma 
is  denuded,  the  red  surface  should  be  painted  with 

R   Acidi  tannici,   ^ij  (8  grammes); 
Glycerini, 
AquEe  destilL,  aa  5!  (30  grammes). 

The  mother  should,  however,  be  warned  that  this  stains  linen, 
and  that  therefore  only  the  necessary  number  of  diapers  should  be 
sacrificed  for  this  use. 

If  the  skin  is  only  red,  but  not  excoriated,  it  should  be  dusted  with 

R    Zinci  oxidi,  3i  (4  grammes)  ; 
Amyli,   gi  (HO  grammes). 

Other  remedies  recommended  are  lanolin,  vaseline,  sweet  oil,  and 
cold-cream. 

§  2.  Eczema. — Sometimes  the  scalp  of  new-born  children  becomes 
the  seat  of  a  vesicular  and  pustulous  eruption  on  a  red  ground.  The 
vesicles  and  pustules  coalesce,  rupture,  and  are  replaced  by  crusts, 
which  together  with  seborrhoea  and  dust  may  form  a  cap  nearly  cov- 
ering the  whole  scalp. 

The  laity  call  this  a  milk-crust  and  think  it  should  not  be  touched ; 
but  this  is  a  mistake.  The  proper  thing  to  do  is  to  cover  the  affected 
part  with  a  piece  of  lint  soaked  in  a  mixture  of  equal  parts  of  lead- 
water  and  thin  oatmeal  gruel,  which  is  renewed  when  it  gets  dry, — 
that  is,  three  or  four  times  a  day.  This  softens  and  loosens  the  crusts, 
and  the  nurse  may  help  a  little  with  the  nail  of  her  little  finger  to  get 
them  removed.  When  they  are  gone,  the  skin  should  be  rubbed  twice 
a  day  with  lead  ointment  (p.  764). 

When  the  skin  is  healed,  it  may  be  strengthened  by  the  applica- 
tion of  the  above-mentioned  zinc-starch  powder. 

§  3.  Miliaria ;  Pemphigns. — The  epidermis  may  be  raised  into 
vesicles  filled  with  a  serous  fiuid.  In  miliaria,  or  hydroa,  large  parts 
of  the  body  are  covered  with  small  white  vesicles  of  the  size  of  pin- 
heads  or  millet-seeds.  This  eruption  is  probably  due  to  profuse  per- 
spiration. The  child  should  be  lightly  covered  and  the  affected  parts 
dusted  with  zinc-starch  powder. 

Pemphigus  Neonatorum. — Pemphigus  consists  of  a  smaller  number 
of  larger  vesicles.  This  disease  is  much  more  common  in  nurselings 
than  in  adults.  It  is  not  congenital,  but  appears  a  few  days  after  the 
birth  of  the  child  as  vesicles  varying  in  size  from  that  of  a  pea  to  that 


812  NOTES    ON   DISEASES   OF   NEW-BORN    CHILDREN. 

of  a  hazel-nut.  The  eruption  may  occur  on  any  part  of  the  trunk 
or  extremities,  but  rarely  on  the  inside  of  the  hands  or  the  soles  of 
the  feet.  After  the  rupture  the  skin  is  red  and  shows  the  collapsed 
epidermis.  As  a  rule,  there  is  only  one  eruption,  and  the  disease 
ends  in  recovery  within  a  fortnight.  But  if  the  eruption  is  wide- 
spread and  gives  rise  to  suppuration  or  furunculosis,  the  child  may 
become  feverish,  whereas  ordinarily  the  general  health  is  little  affected 
by  the  disease. 

It  is  contagious,  and  may  be  carried  from  one  child  to  bthers  by 
doctors,  nurses,  and  midwives.  A  microbe  much  like  the  staphylo- 
coccus aureus  has  been  found  in  the  fluid  and  successfully  inoculated. 

A  similar  eruption  may  be  of  syphilitic  origin,  but  then  it  is  con- 
genital,, is  situated  on  the  palms  of  the  hands  and  the  soles  of  the  feet, 
and  is  of  much  greater  importance  than  pemphigus  vulgaris. 

Treatment. — A  tablespoonful  of  boiled  starch  is  added  to  the  bath. 
The  skin  is  dusted  with  zinc-starch  powder  and  denuded  surfaces 
dressed  with  pieces  of  muslin  smeared  with  a  mild  ointment,  such  as 

B    Acidi  borici,  1  part  ; 

Unguenti  vel  petrolati  mollis,  6  parts. 

Of  internal  remedies  arsenic  is  most  recommended,  but  iron  and 
quinine  may  also  be  useful. 

§  4.  Erysipelas. — Erysipelas,  which  used  to  be  seen  frequently 
among  the  children  in  lying-in  hospitals,  has,  thanks  to  antiseptic 
midwifery,  become  a  rare  occurrence. 

The  disease  is  contagious  and  may  be  brought  from  one  person  to 
another.  It  enters  only  through  a  wound,  but  in  the  new-born  child 
there  is  always  a  wound  at  the  navel  and  often  surfaces  denuded  by 
intertrigo.  These  are  also  the  common  places  of  entrance  of  the 
poison,  but  a  scratch  with  a  pin  or  a  nail  may  just  as  well  furnish  the 
opening  necessary  for  admittance.  From  the  point  first  affected  the 
disease  may  spread  more  or  less.     The  issue  is  generally  fatal. 

Treatment. — The  child  must  be  isolated  and  fed  artificially.  Nu- 
merous remedies  are  recommended,  which  always  throws  doubt  upon 
their  efficacy.  Some  limit  their  efforts  to  giving  comfort  by  covering 
the  skin  with  dry  cotton  or  with  compresses  dipped  in  astringent  and 
cooling  solutions,  such  as  the  lead  and  opium  wash  or  a  solution  of 
sulphate  of  copper  or  chloride  of  ammonium  (1  per  cent.).  But 
since  it  is  known  that  the  disease  is  due  to  the  invasion  of  the  strep- 
tococcus erysipelatis,  an  antiseptic  treatment  is  rational.  The  skin  may 
be  dusted  with 

R    Acidi  salicylici,   ^i  (4  grammes)  ; 
Zinci  oxidi,   ^i  (30  grammes)  ; 
Amyli,   J  iij  (90  grammes). — M. 


SKIN   DISEASES.  813 

Carbolic  acid  may  be  used  in  a  2  per  cent,  watery  solution  or 
mixed  with  absolute  alcohol  (from  10  to  15  parts),  on  lint  covering  the 
inflamed  part,  or  mixed  with  a  similar  amount  of  oleic  acid  for  rub- 
bing into  the  skin  a  little  outside  of  the  line  of  demarcation  several 
times  a  day.  But  children  are  very  sensitive  to  carbolic  acid.  When- 
ever it  is  used  the  urine  should  be  examined  frequently,  and  as  soon 
as  it  becomes  dark  and  smoky  this  remedy  should  be  discontinued. 

Bichloride  of  mercury  (1:  2000)  may  also  be  used  for  washing  the 
affected  surface  and  in  permanent  application. 

A  good  way  of  using  the  corrosive  sublimate  is  in  this  solution : 

R    Hydrargyri  chloridi  corrosivi,  gr.  ij-iv  (12-25  centigrammes)  ; 
Tincturae  benzoini  compositse,  ^i  (30  grammes). 

This  is  painted  over  the  whole  affected  surface  and  a  finger's 
breadth  beyond  every  few  hours.  It  forms  a  pellicle  which  in  itself 
may  contribute  to  the  cure  by  excluding  the  air. 

Absolute  alcohol  may  be  painted  over  the  inflamed  surface  at  simi- 
lar intervals. 

All  applications  should  either  be  used  outside  of  the  line  of  de- 
marcation or,  if  used  on  the  inflamed  surface,  they  should  extend  an 
inch  beyond  it,  so  as  to  stop  the  propagation  in  continuity. 

§  5.  Congenital  Ichthyosis. — Ichthyosis  is  a  disease  character- 
ized by  the  thickening  of  the  epidermis,  the  increased  number  of 
sebaceous  glands,  and  the  hypertrophy  of  the  papillary  layer  of  the 
corium.     It  is  sometimes  hereditary. 

In  the  lower  degree — xeroderma — the  epidermis  has  a  dry  and 
grayish  appearance,  and  is  divided  by  numerous  furrows  into  small 
scales.  In  the  higher  degree  the  epidermis  forms  a  horny  cuirass, 
which  may  cover  the  whole  body  and  is  interrupted  by  deep  furrows, 
especiahy  corresponding  to  the  flexor  side  of  the  joints.  The  epider- 
mis is  yellow  and  the  furrows  bright  red,  sometimes  bleeding.  The 
eyes  and  mouth  are  surrounded  by  red  protuberances,  which  give  the 
child  a  horrid  appearance. 

The  milder  degree  is  curable  ;  the  severer  one  soon  ends  in  death. 

Treatment. — Protracted  warm  baths,  inunctions  with  cod-liver  oil, 
lanolin,  or  other  fatty  substances,  to  which  may  be  added  ichthyol  (5 
per  cent.),  and  wrapping  up  in  cloths  soaked  in  the  same,  give  relief 
and  may  in  the  mild  form  produce  a  cure.  Internally  arsenic  is 
recommended. 

§  6.  Sclerema. — Sclerema  begins  as  an  cedema  of  the  feet  and 
calves,  but  extends  in  the  course  of  a  few  days  to  the  abdomen,  the 
upper  extremities,  and  the  face.  The  skin  and  the  subcutaneous 
adipose  tissue  become  stiff,  hard,  and  cold,  so  that  they  cannot  be 


814  NOTES    ON    DISEASES    OF    NEW-BORN    CHILDREN. 

folded.  In  the  beginning  they  retain  impressions  as  other  oedema- 
tous  surfaces,  but  later  they  become  as  hard  as  a  board.  In  places 
the  skin  becomes  fissured.  The  limbs  become  immovable.  The  eyes 
are  half  closed  and  the  mouth  is  diminished.  The  color  is  in  some 
places  pink,  but  mostly  deathly  white,  with  bluish  toes. 

The  temperature  diminishes  several  degrees  daily  and  may  sink  to 
90°  F.  or  lower.  This  combination  of  cold,  stiffness,  and  paleness 
gives  the  body  the  appearance  of  a  frozen  corpse.  The  respiration  is 
shallow^,  the  pulse  slow  (60-75  beats  per  minute).  The  child  is  som- 
nolent, whimpers,  and  cannot  suck. 

Etiology. — The  disease  is  most  often  found  in  premature  or  weak 
children.  Sometimes  there  are  faulty  persistent  communications 
between  the  large  blood-vessels  or  between  the  two  sides  of  the 
heart.  In  other  cases  the  disease  joins  hydrocephalus  or  meningeal 
hemorrhage,  pneumonia,  or  diarrhoea.  Perhaps  the  origin  is  to  be 
sought  in  weakness  of  the  respiratory  muscles,  in  atelectasis  of  the 
lungs,  or  in  injury  to  the  heat-producing  centre. 

The  prognosis  is  bad.  Generally  death  occurs  between  the  second 
and  tenth  days.     Recovery  is  rare. 

Treatment. — If  breathing  is  defective,  the  child  should  be  made  to 
cry  aloud.  It  should  be  kept  warm  by  means  of  hot-water  bottles, 
hot  bricks,  flat-irons,  or  lids  from  the  kitchen  range,  all  properly 
wrapped  up  and  kept  at  such  a  distance  that  the  skin  is  not  burned. 
Massage  with  warm  oil,  vaseline,  or  lanolin  and  passive  movements  are 
indicated  in  order  to  combat  the  cedema  and  stiffness.  Since  the  child 
cannot  nurse,  it  must  be  fed  with  a  teaspoon  or  a  dropper.  Pro- 
tracted and  frequent  warm  baths,  to  which  may  be  added  sea-salt,  are 
useful.  A  mild  galvanic  current  may  perhaps  favorably  impress  the 
case  if  it  is  of  neurotrophic  origin.  Stimulants,  such  as  whiskey  or 
brandy  (4  to  6  drops  in  a  teaspoonful  of  water  every  half-hour), 
tincture  of  digitalis  (1  drop  every  one  or  two  hours),  or  aqua  cam- 
phorae  (10  drops  every  hour),  are  also  indicated. 


CHAPTER   VII. 

DISEASES    OF   THE   DIGESTIVE    ORGANS. 

§  1.  Colic. — When  the  child  cries,  the  most  common  explanation 
is  that  it  is  hungry.  If  that  is  so,  it  will  stop  crying  when  fed.  But 
most  new-born  children,  those  who  nurse  as  well  as  the  bottle-fed, 
suffer  from  time  to  time  from  pain  in  the  bowels,  which  they  show  by 
making  faces,  sometimes  much  like  a  smile,  and  by  drawing  up  their 
knees.     An  excellent  remedy  for  this  is — 


DISEASES    OF   THE   DIGESTIVE   ORGANS.  815 

R   Spts.  aetheris  co.,   ^ss  (2  grammes)  ;  ^ 

Tinct.  rhei,   giii  (12  grammes). — M. 
Sig. — Seven  drops  to  be  administered  in  a  teaspoonful  of  sweetened  water  four 
times  a  day. 

§  2.  Constipation. — Normally  a  new-born  child  ought  to  have 
three  or  four  pultaceous  yellow  movements  a  day.  But  not  infre- 
quently they  have  only  one  hard  movement  daily,  or  even  less.  The 
expulsion  of  this  causes  pain,  and  sometimes  even  a  little  blood  streaks 
the  hard  lumps.     The  abdomen  is  often  hard  and  tense. 

If  the  child  is  bottle-fed,  we  have  already  indicated  some  changes 
to  be  made  in  the  composition  of  its  food  (p.  251).  If  laboratory 
milk  is  used,  the  amount  of  casein  should  be  reduced  to  one  per  cent. 
or  less  and  the  amount  of  fat  increased.  If  possible  breast-milk 
should  be  substituted  for  artificial  food.  But  even  that  may  not  have 
the  right  composition.  If  the  nurse  has  a  thick,  white  milk,  much 
may  be  gained  by  getting  another  with  thin  bluish  milk. 

If  the  mother  or  nurse  is  constipated  too,  she  should  above  all  be 
treated,  and  a  daily  small  dose  of  sodium  sulphate  (about  a  teaspoon- 
ful in  a  tumblerful  of  water)  should  be  taken  on  an  empty  stomach 
in  the  morning. 

A  piece  of  white  Castile  soap  as  large  as  the  third  phalanx  of  an 
adult's  little  finger  may  daily  be  inserted  into  the  rectum  of  the  child, 
or  a  similar  portion  of  a  glycerin  or  gluten  suppository  may  be  used 
instead.  If  that  does  not  suffice,  half  a  teaspoonful  of  castor  oil  with 
a  little  sugar  spread  over  the  top  may  occasionally  be  given  with  good 
effect.  Calcined  magnesia  (gr.  i-ii — from  6  to  12  centigrammes)  may 
be  given  from  three  to  six  times  a  day.  Pulvis  rhei  compositus,  which 
contains  magnesia,  is  still  more  effective.  The  rhubarb  may  also  be 
given  in  the  shape  of  syrup. 

Massage  may  be  used  to  advantage  either  by  simple  friction  of  the 
abdominal  skin  with  the  flat  hand  or  by  kneading  the  whole  colon, 
beginning  at  the  ceecum  and  following  the  ascending,  the  transverse, 
and  the  descending  colon,  and  repeating  this  circular  movement  for 
several  minutes  three  times  a  day. 

If  the  constipation  is  due  to  defective  peristaltic  movement,  this 
may  be  increased  by  means  of  electricity.  The  galvanic  current  is 
said  to  work  better  than  faradism.  The  negative  pole  should  be 
inserted  into  the  rectum  and  the  positive  be  moved  along  the  course 
of  the  colon. 

§  3.  Diarrhoea. — Diarrhoea  is  more  common  and  of  much  greater 
moment  than  constipation.  It  is  generally  due  to  intestinal  catarrh, 
and  sometimes  combined  with  vomiting,  whether  the  stomach  itself  is 
inflamed  or  not.  The  faeces  become  watery,  greenish,  often  offensive, 
and  mixed  with  much  gas.     Even  if  they  are  yellowish,  the  diapers 


816  NOTES   ON   DISEASES   OF   NEW-BORN    CHILDREN. 

by  exposure  to  the  air  become  greenish.  The  acrid  dejections  chafe 
the  buttocks  and  thighs.  The  child  cries  much,  becomes  weak,  loses 
flesh,  and  becomes  somnolent.  In  bad  cases  the  large  fontanelle  sinks 
deep  in  between  the  bones.  Many  children  lose  their  lives  from  this 
complaint. 

The  disease  is  particularly  common  among  bottle-fed  children. 
Often  it  is  due  to  sour  milk.  In  nursing  children  I  have  often  found 
the  cause  to  be  the  use  of  beer  by  the  mother  or  nurse.  I  inferred 
this  from  the  uselessness  of  the  usual  remedies  and  from  the  recovery 
promptly  following  the  abstinence  from  beer  in  the  nurse.  Instead  of 
digestion  a  fermentation  takes  place  in  the  stomach  or  intestine,  or 
both,  which  is  due  to  microbes.  These  abound  normally  in  the  intes- 
tinal tract  a  few  hours  after  the  birth  of  the  child.  They  are  brought 
in  by  milk,  even  breast-milk,  or  swallowed  with  the  air  or  inserted 
through  the  rectum.  In  the  last  way  the  disease  may  even  become 
contagious. 

Too  frequent  feeding  may  also  cause  diarrhoea.  The  digestive 
organs  do  not  have  time  to  dispose  of  the  food  ingested  before  a  new 
supply  arrives.     The  milk  may  also  be  too  rich  in  fat  or  in  salts. 

Treatment. — A  chief  point  is  to  let  the  organs  have  rest.  The  child 
should,  therefore,  be  fed  with  as  long  intervals  as  possible.  It  is  much 
better  for  it  to  go  hungry  for  six  hours  than  to  have  its  stomach  irri- 
tated by  food  it  cannot  digest.  Thirst  should  be  relieved  by  giving  the 
child  boiled  water,  to  which  whiskey  may  be  added  with  advantage, 
or  a  weak  infusion  of  chamomile  flowers  or  fennel-seed.  If  the  case 
is  at  all  serious  and  does  not  yield  to  medicinal  treatment,  I  suspend 
nursing  altogether  and  substitute  Nestle's  food,  which  seems  to  have 
a  most  happy  drying  effect  on  the  bowels.  The  mother  should  milk 
out  her  breast  several  times  a  day,  to  keep  up  the  secretion.  If  the 
child  is  fed  with  "  modified  milk,"  it  should  be  ordered  with  a  low 
percentage  of  fat  and  salts. 

The  remedy  that  has  given  me  the  best  results  is  nitrate  of  silver : 

R   Argenti  nitratis,  gr.  i  (6  centigrammes)  ; 
Aquae  destillatae,  ^iv  (120  grammes). — M. 
Dispense  in  a  dark  bottle. 
Sig. — A  teaspoonful  every  hour  or  two. 

This  is  particularly  valuable  if,  besides  the  diarrhoea,  there  is  vom- 
iting. When  the  vomiting  stops  and  the  diarrhoea  continues,  it  is  best 
to  give  calomel  (gr.  ^ — 1  centigramme — three  or  four  times  a  day). 
Bismuth  subnitrate,  salicylate,  or  subgallate  (gr.  1-2 — from  6  to  12  cen- 
tigrammes) at  similar  intervals  is  also  good.  It  may  be  given  in  chalk 
mixture,  which  is  an  antacid.  For  the  latter  purpose  calcium  car- 
bonate or  phosphate  (gr.   1-2 — from  6  to  12  centigrammes — every 


TETANUS.  817 

hour  or  every  two  hours)  may  also  be  used.  Besides  the  antifermen- 
tatives  already  named,  resorcin  or  salol  (gr.  ]— ^ — from  15  to  30  mil- 
ligrammes) may  answer  a  good  purpose.  Small  doses  of  opium 
both  relieve  pain  and  moderate  the  peristaltic  movement  (pulv.  Doveri 
gr.  yV-3 — from  6  to  20  milligrammes — every  two  hours). 

At  the  beginning  of  the  treatment  it  may  be  well  to  remove  irri- 
tant substances  from  the  intestinal  tract  by  the  stomach-pump,  high 
enemas  with  soapsuds,  or  half  a  teaspoonful  of  castor  oil. 

If  the  skin-  is  hot,  the  abdomen  should  be  covered  with  cloths 
wrung  out  of  cold  water,  which  are  changed  as  often  as  they  get 
warm,  during  two  or  three  hours.  But  when  the  child  becomes 
chilled  all  over  the  cold  applications  should  be  discontinued. 

As  stimulants  may  be  given  alcohol,  camphor  (gr.  ^-| — from  15  to 
30  milligrammes),  or  Siberian  musk  (gr.  i — 6  centigrammes — every 
half-hour  until  gr.  v-x — from  30  to  60  centigrammes — have  been  used). 

High  enemas  with  hot  water  (100°  F.),  a  little  alcohol,  a  drop  of 
laudanum,  and  boiled  starch  are  stimulating,  tranquillizing,  and  drying. 
They  may  be  repeated  three  times  a  day. 

§  4.  Icterus. — In  the  description  of  the  changes  that  take  place  in 
the  new-born  child  (p.  598)  we  have  mentioned  icterus  neonatorum  as 
being  so  frequent  an  occurrence  that  it  cannot  be  looked  upon"  as  a 
disease.  But  besides  this  benign  form  there  is  a  malignant  form, 
which  constitutes  a  serious,  often  incurable,  ailment.  The  biliary 
ducts  may  be  closed  or  the  child  may  have  congenital  cirrhosis  of  the 
liver,  fatty  degeneration,  or  epidemic  haemoglobin uria,  all  of  wdiichare 
incurable.  Duodenal  catarrh  may  temporarily  block  up  the  common 
bile-duct,  when  the  prognosis  is  better.  Icterus  appearing  in  general 
sepsis  is  ominous.  Often  the  jaundice  is  a  symptom  of  congenital 
syphilis. 

Duodenal  catarrh  calls  for  aperient  medicine,  especially  rheum  or 
calomel.  If  the  disease  is  of  syphilitic  origin,  the  prognosis  is  grave, 
but  a  thorough  specific  treatment  may  sometimes  effect  a  cure. 


CHAPTER   VIII. 
TETANUS. 


Tetanus  neonatorum  is  found  as  a  common  disease  among  the 
natives  of  East  India  and  on  certain  European  islands — St.  Kilda,  one 
of  the  Hebrides,  and  Westmannsoe,  near  Iceland.  Sometimes  so- 
called  epidemics  have  also  occurred  in  the  practice  of  one  midwife. 

True  tetanus  can  only  be  ))roduced  by  the  specific  hacilhis  tetani, 
whicli  enters  through  the  uiubiiical  wound.     But  perhaps  a  similar 

52 


818  NOTES    ON   DISEASES    OF   NEW-BORN    CHILDREN. 

kind  of  spasms  may  be  brought  on  by  an  overheated  bath  or  exposure 
to  cold  or  lesions  of  the  brain  and  the  medulla. 

The  disease  begins  between  the  third  and  the  tenth  day  after  the 
birth  of  the  child.  First  some  spasms  are  noticed  about  the  mouth. 
The  child  cannot  suck  or  soon  lets  go  the  nipple.  Next,  the  mouth 
cannot  be  opened,  the  tetanic  contraction  of  the  masseter  muscles 
causing  lockjaw,  or  trismus.  Within  twelve  hours  the  muscles  of  the 
neck  are  seized,  producing  opisthotonus,  and  thereafter  the  whole  body 
may  be  drawn  into  the  process  and  clonic  may  alternate  with  the  tonic 
convulsions.     The  temperature  may  rise  enormously  (106-111°  F.). 

As  a  rule,  the  disease  ends  fatally  within  twenty-four  hours,  but 
if  it  takes  a  slower  course  the  prognosis  is  better ;  and  if  the  child 
survives  five  or  six  days,  there  is  fair  hope  of  its  recovery. 

Treatment. — As  a  precaution  it  is  wise  to  leave  a  place  where  the 
disease  is  endemic  and  be  confined  at  a  distance. 

If  tetanus  antitoxin  can  be  obtained,  about  yV  of  the  dose  for  an 
adult  should  be  injected  subcutaneously,  and  repeated  if  it  improves 
the  condition  of  the  child.  At  the  same  time  narcotic  and  antispas- 
modic remedies  should  be  used.  Medicine  must  be  given  hypoder- 
mically.  Tincture  of  opium,  ri;,i  (6  centigrammes) ;  sulphate  of  atro- 
pine, gr.  T¥(nr-(5-¥ir  (from  0.06  to  0.1  milligramme) ;  curare,  gr.  gV-sV 
(from  1  to  2  milligrammes) ;  extractum  fabge  calabar,  gr.  -gV-y  (from 
2  to  30  milligrammes),  have  all  effected  cures.  Chloral  hydrate  may 
be  given  by  the  rectum  (gr.  i-v — from  6  to  30  centigrammes — from  six 
to  ten  times  daily).  Chloroform  inhalations  may  be  used  from  time 
to  time. 

Since  the  convulsions  get  worse  by  handling  the  little  patient,  baths 
are  not  practicable.  High  temperature  may  be  combated  with  cold 
applications,  antifebrin,  or  antipyrin. 

The  wound  should  be  cauterized  with  Paquelin's  thermocautery, 
painted  with  tincture  of  iodine,  and  dressed  with  a  solution  of  carbolic 
acid  (1  per  cent.). 

Food  should  be  given  through  the  nose  with  a  medicine-dropper 
or  a  teaspoon. 


CHAPTER   IX. 

DISEASES  OF  THE  AIR-PASSAGES. 

§  1.  Acute  Nasal  Catarrh. — Catarrh  of  the  upper  air-passages  is 
quite  common.  Acute  nasal  catarrh,  popularly  known  as  snuffles,  is 
due  to  a  cold,  draughty  room,  or  a  dry  and  dusty  atmosphere.  Like 
everything  else  which  interferes  with  nursing,  it  acquires  in  the  infant 
an  importance  which  it  has  not  in  the  adult.     The  passages  through 


DISEASES    OF   THE   AIR-PASSAGES.  819 

the  nose  are  very  narrow  and  easily  blocked  up,  but  a  free  circulation 
of  air  through  the  nose  is  necessary  to  the  act  of  sucking.  The  ail- 
ment may,  therefore,  claim  the  attention  of  the  physician. 

The  crib  should  in  the  cold  season  be  placed  away  from  doors 
and  windows.  A  screen  may  also  be  needed  to  protect  the  child 
against  draughts  when  a  door  is  opened.  At  the  same  time  the  room 
should  be  kept  properly  ventilated  and  at  an  even  temperature  of 
about  70°  F.  It  may  be  well  to  cover  the  infant's  head  with  a  cap. 
If  the  nose  becomes  obstructed,  it  may  be  cleaned  with  a  camel's- 
hair  brush  or  an  applicator  wound  with  absorbent  cotton.  This  may 
be  dry  or  moistened  with  a  saturated  solution  of  boric  acid  or  some 
astringent  fluid,  containing  alum,  sulphate  of  zinc,  bismuth,  or — best 
of  all — cocaine  hydrochlorate  (1  per  cent.).  If  the  latter  is  used,  the 
general  effect  should,  however,  be  watched,  and  the  process  should 
not  be  repeated  oftener  than  every  three  hours.  In  mild  cases  it 
suffices  to  let  the  child  inspire  the  vapor  of  warm  water  held  in  a 
cup  in  front  of  the  nose  or  evaporating  from  a  kettle  kept  boiling 
near  the  crib. 

Catarrhal  fever  may  be  combated  with  sodium  salicylate,  quinine, 
antipyrin,  phenacetin,  or  aconite,  and  a  dose  of  Dover's  powder 
towards  night. 

§  2.  Catarrhal  Laryngitis. — Catarrhal  laryingitis  is  attended  with 
fever,  a  hoarse  cry,  and  a  barking  cough. 

Inhalations  of  warm  vapor,  warm  applications  or  salted  bacon 
tied  around  the  neck,  and  a  syrup  containing  opium  or  heroin  are 
indicated. 

§  3.  Atelectasis. — Atelectasis  may  be  congenital  or  acquired. 

The  respiration  is  shallow  and  accelerated.  Air  may  not  enter  in 
one  side  of  the  chest.  If  the  affection  implicates  a  large  part  of  the 
lungs,  percussion-sound  is  dull. 

The  condition  is  dangerous.  It  is  of  paramount  importance  to 
make  the  child  cry.  In  the  congenital  form  all  the  remedies  recom- 
mended above  (p.  559)  for  asphyxia  may  be  used.  In  the  acquired 
form  it  is  practical  to  close  the  mouth  and  nose  from  four  to  eight 
seconds,  which  causes  an  accumulation  of  carbonic  acid  in  the  blood 
and  produces  deep  inspiration.  When  the  acute  stage  is  passed, 
the  child  should  be  carried  about,  and  when  it  lies  down  it  should 
alternately  lie  on  the  two  sides,  not  on  the  back. 

Alcohol  and  camphor  should  be  used  freely.  High  enemas  with 
hot  water,  to  which  alcohol  may  be  added,  have  not  only  a  stimu- 
lating effect  in  virtue  of  the  heat  and  the  mechanical  irritation,  but 
much  water  is  absorbed  and  goes  to  fill  the  blood-vessels  in  the 
lungs. 


820  NOTES   ON   DISEASES   OF   NEW-BORN    CHILDREN. 

CHAPTER    X. 
CONGENITAL   DISEASES   OF   THE    HEART    AND  LARGE  BLOOD-VESSELS. 

Disorders  in  the  circulation  may  be  due  to  a  faulty  development 
or  intra-uterine  inflammation.  The  foramen  ovale  between  the 
atria  may  remain  open  or  the  partition  between  the  ventricles  may 
be  defective,  the  ductus  arteriosus  or  the  pulmonary  arteries  may 
be  too  narrow,  or  the  heart  too  small.  Endocarditis  during  fetal 
development  affects  most  often  the  right  side  of  the  heart.  As  in  later 
life,  it  distorts  the  valves,  causing  stenosis  and  insufficiency. 

Hcematoma  of  the  free  margin  of  the  mitral  valve  is  formed 
under  the  endocardium  immediately  or  soon  after  birth.  It  gives 
rise  to  a  systolic  murmur,  but  is  likely  to  disappear. 

Children  suffering  from  congenital  disease  of  the  heart  and  the 
large  vessels  require  extraordinary  care.  If  nothing  else  can  be 
done  for  them,  they  must  at  least  be  protected  against  cold,  which 
they  stand  badly.  Most  of  these  children,  fortunately,  die  soon.  If 
they  do  not,  digitalis,  iodide  of  potassium,  strychnine,  and  nitroglycerin 
may,  perhaps,  help  them  to  carry  their  burden. 


CHAPTER    XI. 
CYANOSIS. 


The  blue  color  in  a  baby  is  apt  to  inspire  dread  among  the  lay 
bystanders  at  its  birth.  The  intelligent  physician,  however,  is  not 
disturbed  by  this  sight.  In  fact,  he  may  hail  it  as  a  reassuring 
sign.  In  a  case  of  asphyxia  there  is  no  comparison  between  the 
danger  in  which  a  sturdy  violet  baby  is  and  that  of  a  limp  white  one. 
Also  in  atelectasis  there  may  be  a  fair  chance  of  obtaining  good 
respiration,  and  the  same  applies  if  the  "blue  baby"  is  born  pre- 
maturely and  only  suffers  from  weakness.  But  if  the  blue  color 
persists,  it  is  certainly  a  sign  of  some  serious  condition  of  the  cir- 
culatory or  respiratory  organs,  such  as  the  just-mentioned  faulty 
development  of  the  heart  and  large  blood-vessels  or  valvular  dis- 
ease. The  blue  color  may  also  be  due  to  pneumonia,  pleurisy, 
malformations  of  the  air-passages,  or  pressure  on  the  trachea  or 
the  respiratory  nerves — for  instance,  by  an  enlarged  thymus  gland. 

The  treatment  varies  with  the  nature  of  the  case  and  has  partly 
been  described  on  preceding  pages.  Further  information  about  it 
must  be  sought  in  treatises  on  diseases  of  children. 


HEREDITARY   SYPHILIS.  821 

CHAPTER    XII. 
HEREDITARY    SYPHILIS. 

Syphilis  has  a  most  deleterious  effect  on  the  offspring.  Frequently 
it  leads  to  abortion  (p.  341),  which  commonly  occurs  either  in  the 
seventh  or  in  the  third  month.  Nearly  one-half  of  all  syphilitic  chil- 
dren are  still-born,  and  of  those  born  alive  seventy-five  per  cent,  die 
within  a  year  and  most  of  them  within  a  few  days  or  weeks. 

Syphilis  may  be  inherited  either  from  the  father  or  from  the  mother, 
but  if  it  comes  from  the  father  he  generally  infects  his  wife.  Some- 
times the  disease  may  remain  latent  in  her,  but  when  the  eruption 
comes  it  has  the  character  of  a  late  affection,  appearing  as  grouped 
papules  or  deep  ulcers  and  not  as  a  macular  eruption  spread  all  over 
the  body,  as  in  the  first  outbreak  of  secondary  syphilis. 

A  woman  with  secondary  syphilis  nearly  always  gives  birth  to 
syphilitic  children,  even  if  she  was  healthy  at  the  time  of  conception 
■  and  has  been  infected  during  her  pregnancy.  If  syphilis  is  latent  in 
her,  she  may  alternately  bear  syphilitic  or  healthy  children,  which 
probably  finds  its  explanation  in  Virchow's  metastasis  theory,  accord- 
ing to  which  the  blood  is  not  always  contaminated,  the  poison  being 
retained  in  the  solid  parts  of  the  body,  especially  the  lymphatic 
glands,  and  only  at  times  set  in  circulation.  Syphilis  produces  a  cir- 
cumscribed endometritis,  which  may  explain  Avhy  women  may  continue 
for  years  to  have  abortions  or  give  birth  to  syphilitic  children. 

But  in  course  of  time  the  syphilitic  taint  loses  its  strength,  and 
thus  women  with  tertiary  symptoms  in  the  skin,  the  mucous  mem- 
branes, and  the  bones  may  bear  healthy  children,  who  remain 
healthy.  And  so  also  in  regard  to  the  father.  If  a  man  with  recent 
syphilis  marries,  as  a  rule,  he  infects  his  wife  and  begets  syphilitic 
children,  but  if  a  period  of  say  two  years  has  passed  since  he  last  had 
any  symptoms  of  syphilis,  he  rarely  infects  his  wife,  and  they  may 
have  healthy  children. 

How  variable  the  laws  for  hereditary  syphilis  are,  is  illustrated  by 
the  fact  that  of  twins  one  may  be  infected  and  undergo  the  usual 
changes,  while  the  other  escapes. 

Hereditary  syphilis  may  be  congenital,  that  is  the  child  may  be 
born  with  symptoms  of  syphilis,  but  much  more  frequently  the  disease 
appears  between  the  first  and  the  twelfth  week  after  birth.  It  appears 
most  often  during  the  first  month  and  becomes  rarer  in  the  second 
and  still  more  so  in  the  third. 

Symptoms. — The  child  may  be  born  in  apparently  good  health,  but 
soon  nutrition  is  impaired.  The  child  loses  in  weight.  Its  sl<in  be- 
comes too  wide  for  it  and  lies  in  wrinkles  and  folds.    Its  voice  becomes 


822  NOTES   ON    DISEASES   OF   NEW-BORN    CHILDREN. 

weak  and  whimpering.     On  account  of  fissures  at  the  angle  of  the 
mouth,  it  cannot  suck. 

As  a  rule,  syphilitic  children  are  small  and  light.  They  may  also 
be  born  with  jpempkigus^  that  is  apt  to  have  an  exfoliating  character. 
On  all  parts  of  the  body  except  the  scalp,  and  especially  frequently 
on  the  palms  of  the  hands  and  the  soles  of  the  feet,  there  may  be  an 
eruption  of  tense  vesicles,  ranging  in  size  from  a  pea  to  a  hazel-nut. 
Often  these  vesicles  have  become  confluent,  so  as  to  form  large,  irregu- 
lar surfaces,  covered  with  blood  or  pus,  in  the  contour  of  which  hang 
shreds  of  epidermis.  On  other  places  the  skin  is  dry,  ash-colored, 
and  covered  with  seborrhoeal  crusts.  The  last  phalanges  of  the  fingers 
are  apt  to  suppurate,  and  the  nails  may  fall  off.  Such  children  gen- 
erally die  within  a  week ;  but  if  the  disease  takes  other  forms  and 
appears  later,  the  course  is  less  rapid,  and  with  proper  treatment 
there  is  even  a  fair  chance  of  curing  them  and  raising  them. 

Coryza,  or  snuffles,  is  one  of  the  earliest  symptoms.  The  air-pas- 
sages through  the  nose  become  blocked  up,  and  there  is  a  purulent 
discharge  from  the  nostrils.     The  conjunctiva  may  be  inflamed. 

There  may  come  an  eruption  of  pemphigus,  as  described  above. 
Or  there  may  be  red,  elevated  papules,  of  the  size  of  lentils,  generally 
appearing  in  groups  and  limited  to  certain  localities,  especially  the 
face,  the  arms,  the  genitals,  the  palms  of  the  hands,  and  the  soles  of 
the  feet.  But  there  is  never  a  general  eruption  of  macular  syphilides 
as  in  fresh  secondary  syphilis. 

Fissures,  or  rhagades,  form  in  the  lips,  around  the  anus,  or  be- 
tween the  fmgers. 

The  mucous  membrane  near  the  skin  is  also  affected.  On  the 
inside  of  the  lips  and  cheeks,  on  the  palate,  and  on  the  tongue  there 
may  be  excoriations  or  superficial  ulcers,  but  not  well-developed 
mucous  patches. 

The  voice  may  be  harsh  and  deglutition  difficult,  so  that  the  milk 
is  not  swallowed,  but  ejected  through  the  nose. 

The  folds  at  the  anus  are  swollen  and  often  fissured,  which 
causes  painful  defecation.  The  ear  is  not  rarely  the  seat  of  a  deep 
inflammation,  and  even  gangrene,  which  gives  rise  to  an  offensive 
discharge. 

The  internal  organs  are  no  less  affected.  An  abscess  may  form 
in  the  thymus  body.  The  lungs  may  offer  an  aspect  that  has  been 
called  ivldte  hepatization,  or  contain  gummata.  The  liver  and  spleen 
are  often  enormously  enlarged.  In  the  liver  the  inflammation  often 
follows  the  branches  of  the  vena  porta — pylephlebitis.  The  long 
bones  are  affected  in  a  very  peculiar  way,  which  even  is  seen  in 
the  macerated  foetus.  Between  the  diaphyses  and  epiphyses  of  the 
long  bones  there  is  a  broad  zone  of  ossification  with  very  irregular 


HEREDITARY   SYPHILIS.  823 

prolongations.  Among  the  bony  tissue  are  islands  of  cartilage,  and 
in  the  cartilage  are  found  ossified  nuggets. 

In  very  rare  cases  the  child  may  be  infected  during  labor  by 
being  pressed  against  mucous  patches  on  the  maternal  genitals.  But 
then  the  disease  will  appear  later  and  have  the  character  of  acquired 
and  not  of  hereditary  syphilis.  In  the  former  we  have  a  general 
macular  eruption,  mucous  patches,  and  swollen  lymphatic  glands, 
while  in  the  latter  there  is  a  vesicular  or  papular  eruption,  rhagades, 
etc.,  but  not  mucous  patches  or  adenitis. 

Prognosis. — With  the  exception  of  the  syphilitic  pemphigus,  the 
prognosis  in  hereditary  syphilis  is  not  bad.  Under  proper  treat- 
ment recovery  usually  ensues  in  from  four  to  eight  weeks,  and 
some  of  the  children  remain  well.  In  others  there  may  be  a  slight 
relapse,  which  yields  easily  to  specific  treatment.  But  others  are 
less  fortunate.  They  may  become  the  prey  of  furunculosis,  pneu- 
monia, or  diarrhoea,  which  exhausts  their  strength  and  puts  an  end 
to  their  hves.  A  few  may  develop  tertiary  forms,  such  as  gum- 
mous  tumors  in  the  skin  or  periostitis. 

If  the  child  is  born  alive,  the  question  arises,  How  shall  it  be  fed  ? 
The  general  teaching  is  that  the  syphilitic  child  cannot  do  its  mother 
any  harm,  whether  she  shows  signs  of  the  disease  or  not,  and  the 
usually  puny  child  should  have  the  advantage  of  being  nursed  by  its 
mother.  Even  if  she  appears  healthy,  she  will  have  latent  syphilis 
and,  therefore,  be  immune.  It  is  true,  there  are  cases  on  record  in 
which  the  children  after  their  birth  communicated  syphilis  to  their 
apparently  healthy  mothers  who  nursed  them,  but  this  is  so  exceed- 
ingly rare  that  it  practically  may  be  left  out  of  consideration. 

To  use  a  wet-nurse  would  be  criminal  and  might  lead  to  a  suit  for 
damages,  since  she  would  be  sure  to  get  the  disease  from  the  nursling. 
If  the  mother  refuses  to  take  the  risk,  which  in  her  case  is  very  small, 
the  child  must  be  brought  up  on  artificial  food. 

Treatment. — Calomel  (gr.  -jL  to  ^ — from  5  to  10  milligrammes)  two 
or  three  times  a  day  is  well  borne.  If  the  child  has  diarrhoea,  pulvis 
Doveri  (gr.  -^-^ — from  3  to  5  milligrammes)  may  be  added  to  each 
dose.  It  is  better  to  avoid  inunction  with  blue  ointment,  since  the 
fine  skin  of  the  baby  stands  it  less  well,  and  there  often  are  exco- 
riated surfaces.  If  necessary,  it  is  used  in  10-grain  doses — 60  centi- 
grammes— once  daily.  Corrosive  sublimate  has  been  administered  in 
an  entire  bath  (gr.  xv  to  5  gallons  of  water),  but  it  is  better  to  avoid  it, 
the  same  objections  applying  to  mercurial  baths  as  to  inunction.  Ex- 
ceptionally, it  may  be  given  hypodermically  (gr.  -gV-jV — from  1  to  2 
milligrammes)  once  or  even  twice  a  day  dissolved  in  water  (240  parts). 

Excoriations  are  soothed  and  their  healing  favored  by  the  daily 
administration  of  a  warm  bath  with  bran  or  starch. 


824  NOTES   ON   DISEASES   OF   NEW-BORN    CHILDREN. 

Fissures  may  be  smeared  with  tlie  boiled  lead  ointment,  of  which 
I  have  given  the  formula  above  (p.  764),  or  iodoform  ointment  (1  :  4). 
Or  they  may  be  painted  with  a  solution  of  ferri  et  potassse  tartratis 
(1 :  20),  or  once  a  day  with  a  solution  of  nitrate  of  silver  (1 :  50). 


CHAPTER   XIII 
HEMORRHAGE. 


We  have  already  mentioned  bleeding  from  the  umbilical  cord 
(p.  801),  but  other  localities  may  also  be  the  source  of  hemorrhage, 

§  1.  Hemorrhage  from  the  Vagina. — A  bloody  discharge  from 
the  vagina  is  not  very  rare  in  new-born  girls.  It  is  without  impor- 
tance and  gets  well  without  treatment.  It  seems  that  the  great  func- 
tions preparing  in  the  uterus  and  the  breasts  of  the  mother  towards 
the  end  of  pregnancy  have  their  analogon  in  the  child,  producing  a 
congestion  to  the  corresponding  organs.  Hence  the  mastitis  that  is  so 
common  in  new-born  children,  male  as  well  as  female,  and  the  bloody 
discharge  from  the  female  genitals,  due  to  a  condition  of  the  uterine 
mucosa  like  that  of  menstruation. 

If  the  physician  finds  it  necessary  to  do  something,  he  may  order 
vaginal  injections  of  a  few  ounces  of  diluted  lukewarm  liquor  ferri 
chloridi  ("^viii  to  5iv — 50  centigrammes  to  120  grammes),  but  it  is 
better  to  leave  the  discharge  to  the  vis  medicatrix  naturae. 

§  2.  Hemorrhage  from  the  Intestinal  Tract. — Bleeding  from 
the  rectum  is  a  much  more  serious  matter.  It  is  a  symptom  of  the 
disease  called  melcena.  Large  quantities  of  dark  fluid  blood  may  be 
evacuated  from  the  anus,  and  blood  may  also  be  vomited.  Sometimes 
there  are  ulcers  on  the  mucous  membrane  of  the  stomach  and  the 
duodenum ;  but  in  other  cases  there  are  no  ulcers  and  no  ruptured 
blood-vessels  to  be  seen,  and  still  there  is  not  only  found  blood  in  the 
intestinal  canal,  but  also  in  the  peritoneal  cavity. 

The  true  nature  of  the  disease  is  unknown.  Some  think  it  is  due 
to  minute  emboli  coming  from  the  umbilical  vein.  Others  take  it  to 
be  caused  by  an  invasion  of  fungi.  Others  again  attribute  it  to  com- 
pression of  the  head  during  labor.  In  this  connection  I  may  mention 
that  I  have  seen  extravasation  of  blood  in  the  suprarenal  capsules  after 
a  difficult  forceps  delivery. 

The  pulse  soon  becomes  insensible,  the  skin  is  cold,  and  the  child 
will  not  nurse.  The  disease  is  generally  fatal,  and  death  occurs  in 
two  or  three  days. 

From  a  diagnostic  stand-point  it  should  be  remembered  that  if  a 
child  vomits  blood,  it  may  be  maternal  blood,  sucked  from  a  sore  nip- 


HEMORRHAGE.  825 

pie  ;  but  then  the  quantity  is  of  course  small,  and  the  child  would  not 
get  seriously  ill.  If  blood  from  this  source  went  through  the  intestine, 
it  would  become  thick  and  tarry  when  evacuated  from  the  bowel. 

Treatment. — A  case  has  been  reported  which  was  successfully 
treated  with  extract  of  suprarenal  capsule.  Twelve  grains  were 
administered  in  twenty-four  hours.  The  dry  powder  is  put  into  the 
mouth,  and  no  water  must  be  given  with  it. 

The  strong  haemostatic  effect  of  this  drug  taken  internally  or  ap- 
plied locally  in  all  kinds  of  hemorrhage,  is  a  great  inducement  to  use 
it  in  a  disease  in  which  therapeutics  thus  far  has  accomplished  so 
little.  Otherwise,  the  tincture  of  chloride  of  iron,  ^^1-11  (from  6  to  12 
centigrammes)  every  one  or  two  hours,  hydrastinine  in  a  5  per  cent, 
solution,  5  drops  subcutaneously,  or  ergotine  may  be  tried,  and  under 
all  circumstances  the  child  must  be  kept  warm  to  counterbalance  the 
internal  loss  of  heat. 

§  3.  Hemorrhage  from  the  Kidneys  ;  Acute  Hsemoglobinuria ; 
"Winckel's  Disease. — Small  but  very  fatal  endemics  have  arisen  in 
lying-in  hospitals  of  a  disease  in  which  the  urine  becomes  loaded  with 
haemoglobin.  Of  29  children  thus  affected  24  died.  At  first  the  skin 
becomes  cyanotic,  and  later  icteric.  The  urine  has  a  brownish  color. 
The  faeces  become  dark  brown.  The  children  refuse  to  nurse,  and 
nearly  all  die  in  the  course  of  a  few  days. 

At  the  autopsy  were  found  hemorrhagic  infarct  of  the  lungs,  fatty 
degeneration  of  the  liver,  interstitial  nephritis,  and  a  swollen  spleen. 

The  disease  has  been  attributed  to  infection  with  bacterium  coli 
commune  found  in  the  well  water  with  which  the  mouths  of  the  chil- 
dren were  washed,  but  it  is  doubtful  if  that  is  the  real  cause. 

§  4.  Acute  Patty  Deg-eneration ;  Buhl's  Disease. — This  affec- 
tion has  some  important  points  in  common  with  the  preceding.  In 
fact,  it  is  perhaps  the  same  disease,  and  some  think  that  both  are 
streptococcus  infection. 

Most  of  the  children  were  born  asphyctic.  They  showed  great 
tendency  to  bleeding  from  the  navel,  which  resisted  all  treatment. 
There  were  extravasations  of  blood  under  the  skin,  and  blood  was 
evacuated  by  the  anus  and  vomited.  Sometimes  there  was  also  nose- 
bleed. Within  from  three  to  six  days  the  skin  became  icteric.  Most 
of  the  children  died  within  two  weeks. 

The  autopsy  showed  bloody  extravasation  in  the  pleura,  peri- 
cardium, and  meninges,  the  skin  and  mucous  membranes,  the 
muscles,  and  the  thymus  body.  Secondly,  there  was  found  acute  fatty 
degeneration  of  the  liver,  the  myocardium,  the  intestinal  villi,  and  the 
epithelium  of  the  convoluted  tubules  of  the  kidneys. 

The  disease  is  said  to  be  found  also  in  the  sheep  and  the  hog,  and 
there  to  be  hereditary,  especially  in  certain  varieties. 


826  NOTES    ON   DISEASES   OF   NEW-BORN    CHILDREN. 

§  5.  Pulmonary  Apoplexy. — In  rare  cases,  when  a  child  cries  or 
coughs  much,  a  blood-vessel  may  rupture  in  its  lungs.  There  is  then 
a  bloody  discharge  from  the  mouth,  which  soils  the  clothes  and 
frightens  the  friends,  but  in  reality  is  not  serious.  I  would  recom- 
mend the  extract  of  suprarenal  capsule. 


CHAPTER   XIV. 

DEFORMITIES. 

§  1.  Harelip. — If  the  child  can  nurse,  it  is  better  to  defer  the 
operation  for  a  few  months  ;  but  if  the  deformity  prevents  the  child 
from  taking  the  breast,  it  is  better  to  perform  the  operation  at  once. 
By  placing  silver  sutures  before  cutting,  the  loss  of  blood  is  so  small 
that  it  does  in  no  way  weaken  the  child. 

§  2.  Cleft  Palate. — This  condition  prevents  the  infant  from  forming 
that  vacuum  in  its  mouth  which  is  necessary  for  drawing  the  milk  from 
the  breast,  and  the  operation  for  it  is  so  tedious,  painful,  and  bloody 
that  it  is  not  advisable  to  subject  a  new-born  child  to  it.  Some  dental 
surgeons  have  been  very  successful  in  adapting  to  the  cleft  an  obturator 
that  supplements  the  deficient  partition  between  mouth  and  nose. 
Perhaps  also  a  rubber  flap  attached  over  the  nipple  of  the  bottle  may 
enable  the  child  to  suck. 

§  3.  Tongue-tie,  or  Ankyloglossum. — If  the  frasnum  of  the  tongue 
is  too  short  or  prolonged  too  far  forward  it  interferes  ■«ith  the  free 
mobility  of  that  organ,  and  may  thus  constitute  an  impediment  to 
nursing,  which  easily  can  be  removed  by  a  little  operation.  A  bifid 
director  (Fig.  503)  is  passed  so  as  to  lift  the  tongue  and  embrace  the 

Fig.  503. 


Director  for  tongue-tie. 


fraenum,  which  then  is  cut  with  a  pair  of  blunt,  curved  scissors  under 
the  director.  A  little  pressure  with  sterile  gauze  will  soon  arrest  the 
bleeding. 

§  4.  Bncephalocele,  or  Hernia  Cerebri ;  Meningocele. — A  part 
of  the  brain,  covered  with  its  meninges,  may  protrude  from  the 
cranium  so  as  to  form  a  tumor  under  the  skin.  This  is  called  encepha- 
locele,  or  hernia  cerebri.  It  is  always  found  in  a  fontanelle  or  suture, 
most  commonly  the  small  fontanelle,  or  between  forehead  and  nose. 


DEFORMITIES.  827 

That  in  front  may  have  the  size  of  a  hen's  egg,  while  that  behind 
may  be  as  large  as  the  whole  head. 

The  tumor  is  globular,  symmetrical,  often  pedunculated,  covered 
with  normal  skin,  pulsating,  and  increases  by  crying  and  other  forced 
expiration.  It  is  opaque  unless  it  is  complicated  with  hydrocephalus. 
It  can  be  more  or  less  replaced.  It  is  a  rather  rare  deformity.  I  have 
seen  only  one  of  each  of  the  two  varieties  mentioned. 

Diagnosis. — Formerly  it  was  confounded  with  cephalcematoma,  but 
this  is  situated  on  a  bone  and  cannot  be  replaced. 

The  prognosis  is  doubtful,  the  worse  the  larger  the  tumor  is.  The 
combination  with  hydrocephalus  makes  it  also  more  unfavorable. 

Treatment. — The  tumor  should  be  protected  against  injury,  with 
which,  when  it  is  small,  slight  compression  may  be  combined.  Ope- 
rations are  usually  fatal,  but  most  parents  will  prefer  this  issue  to 
having  a  deformed  child. 

The  base  may  be  surrounded  by  an  elastic  ligature  ;  or  the  tumor 
may  be  cut  off  and  the  edges  united  by  suture.  If  it  is  combined  Avith 
hydrocephalus,  it  may  be  punctured. 

If  the  dura  mater  alone  forms  the  pouch,  and  no  brain  matter  is 
prolapsed,  the  condition  is  called  meningocele.  The  prognosis  is  better 
and  the  treatment  the  same  as  for  encephalocele. 

§  5.  Spina  Bifida,  or  Hydrorrhachis. — There  is  some  analogy 
between  encephalocele  and  meningocele  on  one  side  and  spina  bifida 
on  the  other.  While  the  former  consists  in  an  imperfect  closure  of 
the  cranium  and  protrusion  of  the  brain  or  its  meninges  through  the 
opening,  in  spina  bifida  there  is  a  congenital  absence  of  one  or  more 
vertebral  arches,  and  through  the  gap  protrude  the  spinal  meninges, 
forming  a  bag  filled  with  cerebrospinal  fluid  (Fig.  318,  p.  402).  This 
deformity  is  much  more  common  than  the  preceding  one. 

As  a  rule,  there  is  only  one  such  hernia,  and  that  in  the  lumbar 
region  ;  but  exceptionally  two  or  three  have  been  found  in  other  por- 
tions of  the  spine  of  the  same  individual. 

A  globular  or  circular  soft  tumor  is  found  in  the  median  line 
of  the  back.  If  the  opening  through  which  it  connects  with  the 
spinal  canal  is  small,  it  may  be  pedunculated,  but  if  the  opening  is 
large  the  tumor  is  sessile.  It  may  be  covered  with  skin,  but  more 
often  this  is  absent,  and  the  posterior  wall  is  formed  only  by  the 
dura  mater.  In  the  circumference  is  felt  a  bony  ring,  formed  by 
the  edges  of  the  vertebral  canal.  The  swelling  increases  during  the 
child's  crying,  and  can  be  more  or  less  reduced  by  pressure;  but 
the  latter  is  not  without  danger,  since  it  may  produce  paralysis  or 
convulsions. 

Not  infrequently  the  defect  in  the  spine  is  combined  with  hydro- 
cephalus or  club-foot  or  both.     Often  the  whole  cord  or  the  corda 


828  NOTES    ON    DISEASES    OF    NEW-BORN    CHILDREN. 

equina  is  deflected  into  the  tumor,  or  spinal  nerves  may  take  their 
course  in  its  wall. 

In  the  milder  degrees  there  are  no  symptoms  beyond  the  appear- 
ance and  characters  of  the  tumor,  but  in  the  severe  cases  there  may 
be  paraplegia  and  paralysis  of  the  musculature  of  the  bladder  and  the 
rectum.  A  sudden  rupture  of  the  bag  is  accompanied  by  outflow  of 
cerebrospinal  fluid,  convulsions,  and  generally  death. 

The  diagnosis  is  not  difficult,  when  we  pay  attention  to  the  site,  the 
compressibility,  the  increase  in  size  during  crying,  and  the  bony  ring 
in  the  circumference.  By  these  features  spina  bifida  is  distinguishable 
from  cysts  and  solid  tumors. 

The  prognosis  is,  upon  the  whole,  unfavorable.  ]\Iost  of  these 
children  die  ;  but  if  the  tumor  is  small,  and  especially  if  it  is  covered 
with  skin,  they  may  live  and  grow  up.  The  communication  with  the 
spinal  canal  may  close,  and  the  remainder  of  the  tumor,  having 
become  isolated,  can  easily  be  removed  without  danger. 

Treatment. — The  tumor  should  be  covered  with  a  soft  pad,  and  be 
protected  against  pressure.  The  most  successful  treatment  consists  in 
injection  of  iodine.  A  single  drop  of  the  tincture  injected  into  the  sac 
has  led  to  agglutinative  inflammation  and  a  cure.  But  the  method 
that  has  given  the  best  results  consists  in  letting  out  about  one-half  of 
the  fluid  with  a  fine  aspirator  needle  and  injecting  from  5ss  to  ^ii  (from 
2  to  8  grammes)  of  this  fluid : 

R   lodi,  gr.  X  (60  centigrammes)  ; 
Potassii  iodidi,  ^ss  (2  grammes)  ; 
Glycerini,  q.  s.  ad  ^i  (30  grammes). — M. 

In  making  the  puncture  the  median  line  should  be  avoided,  on 
account  of  the  possible  presence  there  of  the  cord.  During  the  ope- 
ration the  child's  head  should  be  held  low,  and  no  pressure  should  be 
exercised  on  the  tumor.  The  opening  is  closed  with  a  piece  of  court- 
plaster  and  collodium.  After  closure  of  the  wound  slight  compression 
is  used  to  prevent  too  rapid  refilling  of  the  pouch.  If  successful,  the 
operation  may  be  repeated  in  a  few  weeks. 

The  frecjuent  presence  of  parts  of  the  nervous  system  in  the  sac 
excludes  the  use  of  the  ligature,  and  cutting  operations  have  nearly 
always  proved  fatal.     The  severe  form  is  incurable. 

§  6.  Umbilical  Hernia. — The  umbilicus  is  the  last  point  closed  in 
the  formation  of  the  body,  and  especially  the  abdominal  cavity.  This 
closure  may  be  more  or  less  imperfect,  and  then  the  result  is  an  um- 
bilical hernia.  In  the  minor  degree  the  intestine  drives  the  umbilical 
cone  forward  as  a  little  skin-covered  tumor  of  the  shape  and  some- 
times of  the  size  of  the  last  phalanx  of  the  thumb  of  an  adult.  This 
is  easily  reduced  by  pressure  with  a  little  button  about  an  inch  in 


DEFORMITIES.  829 

diameter,  convex  and  smooth  on  one  side  and  flat  and  rough  on  the 
other  (Fig.  504),  which  button  is  appUed  with  its  convexity  towards 
the  umbilicus  and  kept  in  place  with  a  piece  of  rubber  adhesive  plaster. 
When  this  gets  loose  it  is  renewed,  and  this  truss  is  used  until  the 
child  has  outgrown  its  hernia,  which  may  take  several  months. 

In  the  higher  degree  of  umbilical  hernia  there  is  a  defect  in  the 
abdominal  wall.     The  skin  and  other  parts  comprising  the  abdominal 
wall  are  lacking  on  a  certain  area  around  the  place 
where  the  umbilicus  should  have  been  formed.  ^^'^^-  '^^^■ 

Through  this  gap  the  intestinal  knuckles  and  per- 
haps part  of  the  liver  protrude,  only  covered  with 
amnion.     If  the  defect  is  no  larger  than  to  allow  xavei  button 

one  to  bring  the  edges  together,  these  ought  to 
be  pared  at  once  and  united  by  sutures  as  after  laparotomy.     Since 
the  child  may  be  expected  to  cry  much  and  to  become  dirty,  it  is 
preferable  to  use  silver  wire  for  the  stitches,  which  do  not  absorb 
fluid,  act  as  splints,  and  even  have  antiseptic  properties. 

§  7.  Atresia  Ani. — We  have  stated  above  (p.  246)  that  if  a  child 
does  not  pass  any  meconium  during  the  first  twenty-four  hours  of  its 
life  its  failure  to  do  so  is  often  due  only  to  an  agglutination  of  the 
epithelium  in  the  anal  canal,  and  all  that  is  needed  to  produce  a 
copious  movement  of  the  bowels  is  to  introduce  the  well-greased  lit- 
tle finger  into  the  rectum.  But  it  is  quite  another  thing  if  there  is 
no  anus  and  perhaps  no  rectum  either.  If  there  is  only  a  more 
or  less  thin  septum  between  the  rectum  and  the  anus, — or  the  skin, 
when  there  is  no  anus, — it  should  be  split  with  a  crucial  incision  and 
the  intestine  sutured  to  the  anus  or  skin. 

The  intestine  may  end  as  a  blind  sac  more  or  less  far  up  in  the 
pelvis,  or  it  may  open  into  one  of  the  hollow  organs  of  the  pelvic 
cavity, — the  uterus,  the  vagina,  the  bladder,  or  the  urethra.  The 
pelvis  of  the  new-born  child  measures  only  from  one  to  one  and 
a  half  inches  in  diameter,  and  it  is  exceedingly  difficult  to  perform 
any  operation  in  so  narrow  a  space.  The  mechanical  difficulties  cre- 
ated by  the  lack  of  room  are  enhanced  by  the  obscurity  in  which 
the  precise  diagnosis  often  is  shrouded.  The  operator  gropes  in  the 
dark,  afraid  of  causing  perhaps  irreparable  lesions. 

If  the  bowel  cannot  be  reached  from  below,  the  propriety  of  colos- 
tomy or  enterostomy  may  be  entertained.  If  determined  upon,  right 
lumbar  colostomy  is  indicated  on  account  of  the  possibility  of  the  ab- 
sence or  malposition  of  the  descending  colon.  For  the  details  of  these 
operations  the  reader  is  referred  to  treatises  on  operative  surgery. 
The  prognosis  is  very  doubtful. 


830  NOTES   ON   DISEASES    OF   NEW-BORN    CHILDREN. 

CHAPTER    XV. 
SUDDEN   DEATH    OF   THE    BABY. 

If  the  child  hes  in  the  mother's  bed,  she  may  unwittingly  roll  over 
it  and  smother  it.  That  the  same  can  be  done  with  criminal  intent 
need  hardly  be  added. 

Death  without  disease  may  be  due  to  apoplexy,  a  cerebral  vessel 
bursting  under  the  blood-pressure  caused  by  violent  and  prolonged 
crying.  A  sudden  congestion  of  the  thymus  gland  may  compress  the 
trachea  and  thus  give  rise  to  asphyxia.  There  may  be  defects  in  the 
internal  organs,  for  instance,  imperforate  ureters,  or  some  other  con- 
dition incompatible  with  life. 


INDEX 


Abdomen,  pendulous,  420. 
Abdominal  pressure,  faulty,  361. 

tumors   obstructing   genital   canal, 
433. 
Abortion,  262. 

artificial,  269. 

complete,  264. 

criminal,  270. 

habitual,  268. 

incomplete,  264. 

missed,  276. 

tubal,  308. 
Abscess,  placental,  354. 
Acardiacus,  259. 
Acetabulum,  133. 
Adenitis,  735. 
.Edoeitis,  702,  707,  729. 
^Edceocolpitis,     gonorrhoeal,     in     child, 

806. 
After-birth,  198. 

expulsion  of,  176. 
After-coming  head,  delivery  of,  384. 

occipitoposterior  position,  380. 
After-pain,  197,  231. 
Agalactia,    758. 
Air,  entrance  into  vein,  786. 
Alcohol,  580. 

Alimentary  canal,  disturbances,  717. 
Allantois,  37,  40. 
Amenorrhoea,  17. 
Amnion,  40. 

false,  40. 

true,  40. 
Amputation,  intra-uterine,  347. 

supravaginal,  670. 

utero-ovarian,  670. 
Anaemia,  788. 

progressive  pernicious,  336. 
Anesthesia,  203,  592,  016,  629. 
Anatomy  of  the  parturient  canal,  130. 
Anencephalus,  403. 
Anteflexion,  297. 
Anteversion,  297. 
Anthrax,  339.    , 


Antiphlogistine,  742. 

Antisepsis,   186,  594. 

in  labor,  725. 
Aphtha^,  Bednar's,  807. 
Arch,  pubic,   141. 
Area   opaca,   36. 

pellucida,  36. 
Areola,  adenitis,  765. 

cellulitis,  765. 

eczema,    337,    765. 

secondary,  93. 

umbilical,  95. 
Arm,  dorsal  displacement,  383,  397. 

liberation,  382. 
Arteritis,  umbilical,  802. 
Arthritis,  718,  744. 
Articulation,   iliosacral,    135. 

separation   of,    546. 
Asepsis,  594. 
Asphyxia,  555. 

Aspirator,   exploratory  vaginal,   736. 
Assistants,   181. 
Atelectasis,  559. 
Atmokausis,  267,  734. 
Atresia,   hymenalis,   427. 
Attitude,  75. 
Auscultation,  111. 
Autoinfection,  700. 
Avulsion  of  head  of  foetus,  563. 
Axis-traction,  GOl. 
Ayer,  symphyseotomy,  649. 

Bacteriology  of  the  vagina,  125. 

Ballottement,  104,  110. 

Bands,  amniotic,  346. 

Barnes,    cervical   dilators,    573,    587. 

Basilysis,  682. 

Basilyst,  683. 

Basiotribe,  682. 

Bath,   cold,   741. 

for   baby,   210. 
Bed,  preparation,  186. 
Bed-sores,  718,  744. 
Bednar,  aphthae,  827. 

.  831 


832 


INDEX. 


Binder,  abdominal,  200. 
Bladder,  434. 

irritability,  334. 
Blastoderm,  36. 
Blastomere,  24. 
Blastos,  36. 
Body,  polar,  24. 

Bonnaire,  dilatation  of  cervix,  586. 
BraeMotomy.  687. 
Braun,  fillet-carrier,  634. 

key-hook,   685. 
Breast,  232. 

chronic  abscess,  773. 

cold  abscess,  773. 

diseases  of,  758. 

erysipelas,  765. 

fistula,  774. 

hypertrophy,  775. 

lymphangeitis.  766. 
Breast-bandage,  236. 
Breast-pump.  236. 
Breech  presentation.  376. 
Brow  presentation.  374. 
Bruit,  uterine,  104. 
Bullae,  718. 
Busch,  version,  625. 

Cesarean  section,  658. 

after  death  of  mother,   551. 

conditions  for,  658. 

for  placenta  praevia.  504. 

Fritsch's,  665. 

indications  for,  658. 

relation    to    other    operations, 
669. 

vaginal.  295,  676. 
Calculation  of  day  of  confinement,  52. 
Calculus.  435. 
Canal,  medullary,  37. 

parturient,  anatomy,   130. 

the  soft  parts,  147. 
pelvic.  141. 
Caput  succedaneum.  178. 
Carbolic  acid  poisoning.  579. 
Carbolism,  579. 
Carcinoma  of  uterus.  293. 
Carunculse  myrtiformes.   121. 
Catamenia,  13. 
Catheterization.  203.  726. 
Cavity,  cotyloid.  133. 

pelvic.  141. 
Cells,  decidual,  27. 
Cellulitis  of  the  limbs,  718. 


Cellulitis  of  pelvis.   709. 

Cephalsematoma.  553. 

Cephalotribe.  681. 

Cephalotripsy.  681. 

Chloasma  uterinum.    94. 

Chloroform-mask,   183. 

Chorea,  323. 

Chorion,   cellular   hypertrophy  of.    352. 

cystic  degeneration  of  the  villi.  349. 

villi  of,  31. 
Cervical  canal,  closure  of,  424. 
Cervix,  155. 

artificial    dilatation    during   labor, 
583. 
during   pregnancy,    566. 

dilatation,  167. 

hsematoma,  523. 

incisions,  588. 

laceration,  534. 

obliteration.   167. 

CEdema,  301. 

old  lacerations,  425. 

rigidity,  425. 

softening,  103. 

stenosis,   425. 

thrombus,  523. 
Champetier   de  Ribes.   cervical   dilator, 

575,  587. 
Chicken-breast,  451. 
Child,  acute  fatty  degeneration,  825. 

ankyloglossum,   826. 

atelectasis,  819. 

atresia  ani.  829. 

Buhl's  disease,  825. 

care  of  new-born,  208,  246. 

catarrhal  laryngitis.  819. 

cleft  palate,  826. 

colic.  814. 

condition  of.   244. 

constipation,  815. 

cyanosis,  820, 

definition  of  living,  558. 

deformities,  820. 

diarrhoea.  815. 

diseases  of  heart  and  blood-vessels, 
820. 
of  the  mouth.  806. 
of  new-born,  801. 

dress  of.  211. 

eczema,  811. 

encephalocele.  826. 

erysipelas,  812. 

erythema,  810. 


INDEX. 


833 


Child,   gonorrhoeal    sedoeocolpitis,    806. 
infection,  803. 
stomatitis,  806. 

haemoglobinuria,  825. 

harelip,  826. 

hemorrhage,  824. 

from  intestine,   824. 
from  kidney,  825. 
from  vagina,  824. 

hereditary  syphilis,  821. 

hernia  cerebri,  826. 

hydroa,    811. 

hydrorrhachis,  827. 

hypertrophy  of  thymus,  810. 

ichthyosis,  813. 

icterus,  598,  817. 

mastitis,  809. 

mela?na,  824. 

meningocele,  826. 

miliaria,   811. 

nasal  catarrh,   818. 

pemphigus,  811. 

puerperal  infection,  802. 

pulmonary  apoplexy,  826. 

sclerema,  813. 

skin  diseases,  810. 

spina  bifida,  827. 

sudden  death,  830. 

tetanus,  817. 

tongue-tie,  826. 

umbilical  hernia,  827. 

Winckel's  disease,  825. 

xeroderma,   813. 
Childbirth  after  death    of    the   mother. 
550. 

chief  features  of,   161. 

permanent  changes  caused  by,  243. 

without  loss  of  blood,  524. 
Cholera,  339. 
Chorio-epithelioma,  752. 
Chorioma,  752. 
Chorion,  31. 

frondosum,  33. 

hyperplasia  of  villi,  352. 

ladve,  33. 

primitive,  31. 

shaggy,  33. 

smooth,  33. 

true,  31. 
Circulation,  46. 

first  embryonic,  46. 

greater,  50. 

lesser,  50. 


Circulation,  placental,  48. 
pulmonary,  50. 
second  embryonic,  47. 
systemic,  50. 

third,  50. 
Circulatory  organs,  diseases  of,  781. 
Cleidotomy,  687. 
Cocainization,  medullary,  204. 
Coccyx,  133. 
Collargolum,  732. 
Colostrum,  96,  232. 
Colpeurynter,  299,  574. 
Colpitis,  284,  702,  707,  729. 

emphysematous,   286. 

mycotic,  286. 
Colpohypoplasia  cystica,  286. 
Comparison    between    forceps    delivery 

and  version,  636. 
Condylomata  acuminata,  289. 
Cone,  umbilical,  71. 

Conglutination  of  the  external  os,  423. 
Conjugate,  available,   140. 

diagonal,   115,    142,   440. 

minimum,    140. 

obstetrical,   140. 

true,   139. 
Constipation,  321. 
Consultation,  594. 
Conti-action,  uterine,  357. 
Contraction-ring,  153. 
Convulsions,  325. 

hysterical,   325. 
Copulation,  18. 

Cord,  anomalies  of  the  umbilical,  355, 
413. 

coiling,  355. 

forked  insertion,  71. 

knots,  355. 

liberation,   194. 

ligation,   195. 

marginal  insertion,   70. 

prolapse,  414. 

protection,  210. 

rupture  of  vessels  in  velamentous 
insertion,   509. 

sound  in  umbilical,  101,  112. 

stenosis,  355. 

too  long,  355. 

too  short,  355. 

torsion,  355. 

umbilical,  42,  70. 

velamentous  insertion,  70. 
Corpus  luteum,  11. 


53 


834 


INDEX. 


Corrosive  sublimate  poisoning,  578. 

Cotyledon,  68. 

Cotyloid  cavity,  133. 

Courses,  13. 

Cranial  vault,  removal  of,  682. 

Cranioclasis,  680. 

Cranioclast,  Braun's,  680. 

J.  Y.  Simpson's,  680. 
Craniopagi,  412. 
Craniotomy,  677. 
Craniotomy-forceps,  682. 
Crede,  B.,  eollargolum,  732. 
unguentum,   732. 

Carl    F.    S.,    disinfection    of    eyes, 
209. 
expression  of  placenta,  197. 
Creolin,  579. 
Cross  birth,  391. 
Crotchet,  684. 
Curettage,  569. 
Curette,  Eecamier's,  569. 

Simon's,  569. 

Sims's,  569. 

Thomas's,  569. 
Cushion,  inflatable  rubber,  182. 
Cyst,  ovarian,  295. 
Cystitis,  777. 
Cystocele,  435. 

Death    of    mother    during    pregnancy, 

345. 
Decapitation,  685. 
Deeidua,  atrophy,  352. 

basilaris,  30. 

capsularis,  30. 

cystic,  352. 

diseases  of,  352. 

hyperplasia,  352. 

hypertrophy,  352. 

menstrual,  14. 

of  pregnancy,  27. 

placentalis  subchorialis,  35. 

reflexa,  29. 

serotina,  29. 

vera,  30. 
Deeiduoma  malignum,  752. 
Decubitus  acutus,  654. 
Degeneration,   lipoid,   309. 
Delivery-room,  219. 
Denidation,  17. 
Depressions,  461. 
Depressor,  Garrigues's,  119. 

Hunter's,  118. 


Desmarre,  retractor,  805. 
Diagnosis  between  first  and  later  preg- 
nancies, 121. 
Diameter  of  Beaudelocque,  117. 
Diaphragm,  pelvic,  151. 
Diarrhoea,  321. 
Dicephalus,  408,  412. 
Dilator,  Arthur  Miiller's,  588. 

Barnes's,  573. 

Champetier  de  Ribes's,  575. 

Garrigues's,  567. 
•    Goelet's,  567. 

Hanks's,   566. 
Discus  proligerus,  6. 
Disinfection,  188,  190. 

in  lying-in  hospitals,  218. 

of  doctors  and  nurses,  724. 

of  instruments,  725. 

of  materials,  724. 

of  patients,  724. 

of  wards,  723. 
Disk,  germinative,  36. 
Displacements  of  uterus,  297,  755. 
Distance,  sacrocotyloid,  139. 
Double  manoeuvre,  Siegemundin's,  635. 
Douche,  preliminary,  202. 
Douche-pan,  181. 
D'Outrepont,  version,  625. 
Drainage-tube,  double,  736. 

skyrocket,  736. 
Duct,  Miillerian,  276. 

Wolffian,  27G. 
Ductus  arteriosus,  48. 

venosus,  48. 
Diihrssen,  deep  cervical  incisions,  588. 

vaginal  Csesarean  section,  676. 
Dyspnoea,  321. 

Ear  presentation,   366. 
Eclampsia,  325,  525,  795, 
Ectoderm,  26,  31,  36. 
Ectomere,  26. 
Eczema  of  areola,  337. 
Elephantiasis  congenita  cystica,  401. 
Elytritis,  284. 
Embolism  of  artery,  781. 

of  pulmonary  artery,  784. 

of  venous  system,  782. 
Embryo,  37. 
Embryotomy,  677. 
Eminence,,  ileopectineal,   135. 
Encephalitis,  744. 
Encephalocele,  401. 


INDEX. 


835 


Endocarditis,  344,  716,  743. 
Endoc'horion,  31. 
Endomere,  26. 
Endometritis,  702,  708,  730. 

cystic,  283. 

decidual,  282. 

hemorrhagic,  283,  352. 

tuberosa  and  polyposa,  283. 
Enema  before  labor,   187. 
Enteritis,  743. 
Entoderm,  26,  36. 
Enucleation  of  the  head,  193. 
Enuresis,  334. 
Epiblast,  36. 
Epignathus,  401. 
Epilepsy,  325. 

Epiphysis,  loosening  of,  462. 
Episiotomy,  428,  541. 
Epithelial  pearls,  808. 
Ergot,  725. 
Erysepelas,  340,  799. 

of  breast,  765. 
Erythema,  718. 
Evisceration,  686. 
Evolution,  spontaneous,  394. 
Examination,  bimanual,   115. 

physical,  107. 

rectal,  117. 

vaginal,  114,  188. 
Excretion,  45. 
Exochorion,  31. 
Exophthalmus,  461. 
Eyelid  retractors,  805. 
Eyes,  disinfection  of,  209. 

Face  presentation,  367. 
Fascia,  pelvic,  151. 

perineal,  151. 
Fecundation,  21. 
Feeding,  artificial,  251. 
Fetation,  multiple,  257. 
Fever,  eruptive,  798. 

malarial,  800. 

of  pregnancy,  335. 
Fever-cot,  740. 

Fibroid  of  abdominal  wall,  758. 
Fillet,  629. 

in  groin,  388. 

mode  of  passing  over  foot,  387. 

on  thigh,  389. 
Fillet-carrier,  388. 

Braun's,  634. 

Routh's,  635. 


Fissure,  460. 

Fistula  of  breast,  774. 

fecal,  780. 

urinary,  778. 
Flow,  monthly,  13. 
Foetus,  aneurism  of  aorta  of,  402. 

ascites  of,  401. 

a^Tilsion  of  head  of,  563. 

carcinoma  of  liver  of,  401. 

changes  in,  after  death,  355. 

cystic  degeneration  of  kidneys,  401. 

death  of,  261. 

development     of,     in     each     lunar 
month,  54. 

distended  bladder,  402. 

emphysema,  402. 

excessive  size,  397. 

expression,   589. 

expulsion,   170. 

fibrocystic     degeneration     of     tes- 
ticle, 401. 

hydronephi'osis,  401. 

hydrorrhachis,  402. 

hydrothorax,  402. 

in  fcetu,  401. 

injurj'  to,  during  labor,  552. 

life  of,  593. 

lymphectasia,  402. 

macerated,  356. 

maturity,  64. 

mummified,  356. 

oedema,  402. 

papyraceus,  356. 

peritonitis,  401. 

sanguinolentus,  356. 

spina  bifida,  402. 

tympanites,  402. 
Fold,  medullary,  37. 

of  Schultze,  72. 
Follicle,  Graafian,  9. 

primary  Graafian.  4,  7. 
Fontanelle,  157. 
Fonticuli  Gasseri,  158. 
Food,  artificial,  249. 
Foot  presentation,  376. 
P'ootling  presentation,  376. 
Foramen  of  Botallo,  47. 

ovale,  47. 
Forceps,  action  of,  602. 

application  of,  606. 

applied  to  after-coming  head,  385. 
to  breech,  390. 

Breus's,  000. 


836 


INDEX. 


Forceps,   Chamberlen's,   596. 

conditions  for  the  use  of,  605. 
construction  of,  594. 
dangers  for  fcstus,  617. 

for  mother,  616. 
delivery  by,  594. 

compared  with  version,  636. 
Elliott's,  598. 

for  carrying  Champetier  de  Ribes's 
dilator,  576. 
rubber  bags  or  gauze  into  the 
uterus,  574. 
high,    middle,    and    low   operation, 

615. 
Hodge's,  599. 
how  it  grasps  head,  611. 
indications  for  the  use  of,  604. 
Levret's,   596. 
Naegele's.  598. 
A.  R.  Simpson's  axis-traction,  595. 

new  model,  602. 
J.  Y.  Simpson's.  598.' 
Tarnier's  axis-traction,  600. 
Forces,  expellant,  163. 
Foretelling  duration  of  labor,  190. 
Formalin,  disinfector,  723. 
Fountain  syringe,  182. 
Fracture,   maternal,    547. 

of  cervical   vertebrae,    462. 
of  collar-bone,  462. 
of  humerus,   462. 
of  skull,  460. 
Fritsch,  Csesarean  section,   665. 
Functions,  fetal,  51. 
Fungus,  umbilical,  801. 
Galactocele.  774. 
Galactorrhoea.  758. 
Galbiati,   falcetta,   648. 

modernized,  648. 
Gangrene  of  leg,  787. 
of  navel,  802. 
of  vagina,  730. 
of  vulva,  730. 
Garrigues,  H.  J.,  apparatus  for  trans- 
fusion and  infusion,  582. 
blunt  expanding  perforator,  736. 
dilator,  567. 
intra-uterine  glass  tube,  577. 

metal  tube,  571. 
L.    F.,    operation    for    salpingitis, 

738. 
occlusion-dressing,   200. 
symphyseotomy-bandage,  653. 


Garrigues,  H.  J.,  weight  speculum,  568. 
Gastro-elytrotomy,  657. 
Gelatin  of  Wharton,  42. 
Genital  cord,  276. 

organs,  diseases  of,  276. 
Gestation,  ectopic,  302. 
Giant  child,  397. 

Gland,  mammary,  during  lactation,  96. 
Globule,  directing,  24. 

extrusion,  24. 
Goelet,  dilator,  567. 
Goitre,  exophthalmic,  344. 
Gonorrhoea,  338. 
Gonorrhoeic  infection,  719. 

of  child,  803. 
Goring,  262. 
Groove,  medullary,  37. 

primitive,  37. 

Hsematoma  of  child's  neck,  462. 

of  vulva,  292. 
Haemophilia,  344. 

Hall,  Marshall,  method  of  reviving,  561. 
Hand,  half  the,  189. 
Hanks,  dilator,  566. 
Harris,  M.  L.,  symphyseotomy,  649. 

Philander,    manual    dilatation    of 
cervix,  585. 
Hay,  director,  649. 
Head,  fetal,  156. 

asymmetry,  178. 
diameters,  160. 

physiological  congenital  asym- 
metry, 460. 
Headache,  322. 
Heart  disease,  343,  525. 
Heart-clot,  782,  784. 
Heart-sound,  fetal,  112. 
Heating,  220. 
Hemicephalus,  403. 
Hemorrhage,  496. 

post-partum,  509,  755. 
secondary,  516, 
umbilical,  801. 
Hemorrhoids,   292. 
Hepatitis,  743. 
Hernia,  344,  433. 

uteri,  301,  423. 
Hicks,  Braxton,  cephalotribe,  681. 

version,  619. 
Hip-bone,  133. 
Hook,  blunt,  389. 
Horlick's  malted  milk,  253. 


INDEX. 


837 


Hunger  cure,  274. 
Hydramnion,  346. 

acute,  348. 
Hydramnios,  346. 
Hydrocephalus,  399. 
Hydrophobia,.  340. 
Hydrorrhoja  gravidarum,  352. 
Hymen,  19. 

cribriformis,   427. 

imperforate,  427. 

septus,  427. 
Hyperemesis,  318. 
Hypertrophy   of   vaginal    portion   in   a 

virgin  simulating  laceration,  122. 
Hypnotism,  208. 
Hypoblast,  36. 
Hypodermoclysis,  581,  734. 
Hysterectomy,  734. 

abdominal,  674. 

vaginal,  675. 
Hysterocele,  301. 

Icterus  neonatorum,  246. 

Ilium,  133. 

Impetigo  herpetiformis,  337. 

Incontinence  of  urine,  777. 

Incubator,  254. 

Induction  of  premature  labor,   572. 

Infarct,  hemorrhagic,   354. 

red,  354. 

white,  354. 
Infection,  forms  of,  691. 

gonorrhceic,  719. 
of  child,  803. 

puerperal,  688. 
Infectious   diseases   complicating   preg- 
nancy, 338. 
Inflammation  of  genitals,  282. 
Influenza,  339,  340. 
Infusion,  582. 
Injection,  intra-uterine,  571. 

intravenous,  581. 

prophylactic,  203,  581. 

subcutaneous,  581. 

vaginal,  577. 
Insanity,  333,  795. 
Insomnia,  322. 
Inversion  of  the  uterus,  516. 
Irrigation,  intra-uterine,  571. 
Isehiopagi,  412. 
Lsi'hiopubiotomy,  654. 
Ischium,  133. 
Ischuria,  776. 


Jaundice,  717. 

Key-hook,  685. 
Kibbee,  fever-cot,  740. 
Kidney,  floating,  758. 

of  pregnancy,  334. 
Knee  presentation,  376. 
Knee-bandage,  544. 
Labor,  abnormal,  357. 

antiseptic  conduct  of,  725. 

causes  of,  129. 

conduct  of  normal,  180. 

duration  of,  179. 

induction  of  premature,  572. 

influence  of,  on  the  child,  178. 
on  the  mother,   177. 

mechanism  of,  173. 

missed,  275. 

normal,  129. 

precipitate,  359. 

premature,  271. 

stages  of,  167. 

twin,  403. 
Labor-bed,  219. 
Labor-pains,  163. 
Laborde,  method  of  reviving,  562. 
Laparo-elytrotomy,  657. 
Laparo-hysterotomy,  658. 
Laparotomy,  741. 
Laundry,  222. 
Leg-holder,  568. 
Legs    extended    in    front    of    foetus    in 

breech  presentation,  379. 
Leptothrix  vaginalis,  286. 
Leucocythaemia,  336. 
Leucomaines,  692. 
Leukaemia,  336. 

Levret,    method     of    delivering    after- 
coming  head,  384. 
Ligaments  of  pelvis,  135. 
Linea  fusca,  95. 
Lipothymia,  322. 
Liquor  amnii,  66. 

scanty,  349. 

folliculi,  5. 
Lithopa?dion,  309. 
Liver,  717. 

foaming,  707. 
Lochia,  227. 

Lying-in  institutions,  216. 
Lymphangeitis.  704,  710,  737. 
Lyniphothrombosis,  703,  710,  737. 
Lysol,  580. 


838 


INDEX. 


Magma  reticule.  4.3.  66. 

Malaria,  339. 

Malformations  of  genitals,  276. 

Mammary  gland,  accessory,  773. 

Marmorek's     antistreptococcic     serum, 

732. 
Mastitis,  337,  766. 

in  child,  809. 
Measles.  339,  779. 
Meconium,  45. 
Membrana  granulosa,  5. 

intermedia,  43. 

propria.  10. 
Membranes,   abnormal,  412. 

extraction,  198. 

pupillary,  65. 

retention  of  parts,  750. 

vitelline,  13. 
Meningitis,  744. 
Menopause,  17. 
Menses,  13. 
Menstruation.  13. 

cessation  of,  102. 
Mesoblast,  36. 
Mesoderm,  36. 
Metritis.  284,  702,  708,  730. 
Microbes,  690. 

non-pathogenic,  692. 

pathogenic,  692. 
Midwives,  211. 
Miliaria,  718. 
Milk,  232. 

anomalous  secretion,  758. 

sterilization,  249. 
Miscarriage,  262. 
Missed  abortion.  276. 

labor,  275. 
Mole,  fleshy,  309,  352. 
Monstrosities,  double,  408. 
Morisani,  symphyseotomy,  648. 
Morning  sickness,  102. 
Morula,  26. 
Mother,  care  of,  233. 

changes  in,  during  pregnancy,   84. 

condition,  226. 

sudden  death,  548. 
Moulding,  178. 
Movement,  fetal,  101. 
Muguet,  806. 

Miiller,  Arthur,  dilator,  588. 
Muscle,  levator  ani,  151. 

of  pelvis,  147. 

of  perineum,  147. 


Muscle-cells,  uterine,  85. 
Myoma  of  uterus,  292. 
Myxoma  fibrosum  placentae,  352. 

Xaegele,  forceps,  598. 

obliquity,  173. 

pelvis.  468. 

perforator,  678. 
Xavel,  diseases  of,  801. 
Xephritis,  334,  717,  743. 
Xervous  system,  diseases  of,  789. 

disturbances,  717. 
Nestle's  food,  253. 
Xeuralgia,  322,  789. 
Xeuritis,  789. 

Xew  York  Maternity  Hospital,  222. 
Xidation,  17. 
Xipple-shield,  763. 
Xipples,  deep  inflammation.  764. 

preparation  for  lactation,  128. 

sore,  761. 
Xubility,  2. 
Xuclein,  734. 
Xursing,  235. 
Xutrition,  43. 
Xutrolactis,  760. 

Obliquity  of  the  head,  lateral,  366. 

of  Xaegele,  173. 
Occlusion-dressing  of  genitals,  200. 
Oidium  albicans,  286. 
Olivier,  fillet-carrier,  388. 
Omphalitis.  802. 
Oophoritis,  703.  709,  737. 
Operations,  obstetric,  565. 

preparation  for,  590. 
Ophthalmia  neonatorum,  803. 
Ophthalmoblennorrhoea,  803. 
Orgasm,  20. 
Os  coxae,  133. 

innominatum,  133. 

pubis,  133. 
Osteomalacia,  483. 
Ovary,  7. 
Ovisacs,  7. 
Ovulation,  2. 
Ovum,  2. 

abnormalities,  412. 

diseases,  346. 

embedding,  27,  29. 

external  migration.  12. 

internal  migration,  12. 

primordial,  4. 


LNDEX. 


839 


Ovum  at  term,  66. 

transportation.  27. 

Pack,  cold.  741. 

warm,  331. 
Palpation,  108.  187.  321. 
Panhysterectomy,  674. 
Paralysis,  324. 

due  to  pressure.  789. 

Erb's,  463. 

facial,  of  child,  616. 

of  upper  extremity,  462. 
Parametritis,  709,  73-5. 
Pasteurization.   250. 
Patient,  preparation  of.   186. 
Patients,  separation  of,  221. 
Pelvic  presentation,  376. 
Pelvimetry,  115,  440. 
Pelvis,  130. 

ankylosed  transversely  contracted, 
475. 

asymmetric.  467. 

axes  of,  141. 

bones.  130. 

brim,  138. 

cavity,  138,  141. 

classification  of  deformities  of,  444. 

contracted,  436. 

by  tumors,  493. 

coxalgic,  471. 

dangers    for    the    foetus     in     con- 
tracted. 459. 
for  the  mother  in  contracted, 
458. 

deformities  of,  436. 

diameters,  139. 

differences   between   male    and    fe- 
male, 144. 
of,  in  different  races.  146. 

flat,  448. 

flattened    by    dislocation    of    both 
femora,  456. 

frequency  of  narrow,  437. 

funnel-shaped.  481. 

generally  contracted  flat,  456. 
equally  contracted,  444. 

inclination,  141. 

incurved,  482. 

infantile,  446. 

inferior  strait,   138,   140. 

inlet,  1.38. 

justo  minor,  444. 

kyphotic,  476. 


Pelvis,  male  type,  445. 

muscles  of,  147. 

nana,  445. 

narrow,  436. 

obliquely  contracted,  468. 

obtecta,  481. 

of  Landouzy.  476. 

of  Xaegele,  468. 

of  new-born,  144. 

of  reclination,  446. 

of  Robert,  475. 

osteomalacic,  483. 

outlet.  130,  138,  140. 

pseudo-osteomalacic  rhachitic,  489. 

rhachitic,  446. 
flat.  449. 
kyphotic.  480. 

scoliotic,  467. 

rhachitic.  467. 

simple  flat,  448. 

split.  494. 

spondylolisthetic.  490. 

superior  strait.  138.  140. 

too  wide.  496. 

transversely  contracted,  474. 

treatment  of  labor  in  flat  and  gen- 
erally contracted  flat,  463. 

without  sacrum,  495. 
sjTuphysis,  495. 
Pemphigus,  337,  718. 

neonatorum,  811. 
Percussion.  111. 
Perforation  of  fetal  head,  678. 
Perforator,     blunt     expanding,     Garri- 
gues's,  736. 

Xaegele's,  678. 

Thomas's,  679. 
Pericarditis,  705,  713,  743. 
Perimetritis.  284. 
Perineorrhaphy,  726. 
Perineum,  fasciae  of,  151. 

laceration  of,  536. 

muscles  of.  147. 

support  of,  192.  540. 
Period,  menstrual,  13. 
Peritonitis,  705,  711,  738. 
Pessary.  299. 
Petechiae,  718. 
Peterson,  colpeurynter,  575. 
Phlebitis,  705,  714.  745.  802. 

uterine,  745. 
Phlegmasia  alba  dolens,  706,  713,  745, 
784. 


840 


INDEX. 


Phlegmasia  cserulea  dolens,  714.- 

Phlegmon,  718. 

Physometra,  458. 

Pinard,  symphyseotomy,  649. 

Placenta,  68. 

abscess  of,  354. 

adherent,  417. 

anomalies  of,  354. 

battledoor,  70. 

calcareous  incrustations,  354. 

double,  69. 

expulsion,  176. 

expression,  196. 

fetal,  68. 

marginata,  355. 

maternal,  68. 

membranacea,  354. 

myxoma  fibrosum,  352. 

praevia,  418,  496. 
cervical,   499. 

premature  detachment  of  normally 
inserted,  505. 

retained,  417. 

retention  of  parts,  751. 

rupture   of   the   circular   sinus   of, 
507. 

suecenturiata,  354. 

tumors  of,  355. 
Placenta-forceps,  570. 
Plate,  parietal,  37. 

somatic,  37. 

splanchnic,  37. 

visceral,  37. 
Pleurisy,  340,  705,  713,  741. 
Pneumonia,  340,  713,  742. 
Polygalactia,  758. 
Polyneuritis,  789. 
Polypus,  decidual,  751. 

fibrinous,  751. 
Pony-room,  219. 
Porro's  operation,  670. 

indications  for,  671. 
Position  for  operations,  591. 

genupectoral,  299. 

occipito-anterior,  362. 

occipitolateral,  365. 

occipitoposterior,  362. 

of  foetus,  81. 

of  the  patient  in  the  three  stages, 
191. 

persistent   mentoposterior,    in   face 
presentation,   371. 

Sims's,  118. 


Post-partum     hemorrhage,     secondary, 

755. 
Posture,  hanging,  591. 
Prague,    method    of    delivering    after- 
coming  head,  385. 
Pregnancy,  abnormal,  257. 

combined  intra -uterine  and  extra- 
uterine, 311. 

complicated  with  chronic  diseases, 
340. 

diagnosis  between  first  and  later, 
121. 

differential  diagnosis  of,  105. 

dress   and   regimen  during,    126. 

duration,  51. 

extra-uterine,  302. 

interruption,  262. 

malignant  tumor  of,  752. 

normal,  27. 

operations  during,  296. 

signs  of,  100. 

spurious,  107. 
Premature  labor,  induction  of,  272. 
Presentation,  anterior  ear,  366. 
parietal.  366. 

breech,  376. 

brow,  374. 

compound,  395. 

face,  367. 

foot,  376. 

footling,  376. 

knee,  376. 

of  foetus,  75. 

pelvic,  376. 

posterior  ear,  366. 
parietal,  366. 

transverse,  391. 
Pressure  marks,  461. 

necrosis  of  vagina,  532. 
of  uterus,  532. 
Procidentia,  300. 
Prolapse,  300. 
Promontory,  131. 

double,  442.     . 

false,  443. 
Pronucleus,  female.  24. 

male,  24. 
Pruritus  AOilvas,  288. 
Pseudocyesis,   107. 
Ptomaines,  692. 
Ptyalism,  321. 
Puberty,  1. 
Pubes,  133. 


INDEX. 


841 


Pubiotomy,  651. 

Puerperal     infection,     curative     treat- 
ment, 728. 
diagnosis,  707. 
etiology,  695. 
localized,  707. 
lymphatic,   707. 
mortality,  719. 
of  child,  802. 
pathology,  702. 
phlebitic,  707. 

prevention     of,     in     hospitals, 
723. 
in  private  practice,  726. 
prognosis,  707. 
sources.  696. 
symptoms,  707. 
treatment,  720. 

ways   by   which   the   infecting 
agent  enters,  699. 
state,  signs  of,  243. 
Puerpery,  225. 
Putrescentia  ovarii,  703. 

uteri,  732. 
Puzos,     method     of     delivering     after- 
coming  head,  384. 
Pyaemia,  706. 

Quadruplets,  258. 
Quickening,  105. 

Piced    and    Carnrick's    lacto-preparata, 
253. 
soluble  food,  253. 
Piecamier,  dull  curette,  569. 
Rectum,  435. 

carcinoma  of,  435. 
Respiration,  46. 

cause  of,  179. 
Rest  after  delivery,  241. 
Retractor,  vaginal,  568. 
Retroflexion,  297. 

partial,  of  the  gravid  uterus,  298. 
Retroversion,  300. 
Rhomb  of  Michaelis,   116. 
Rickets,  451. 
Rosary,  rhachitic,  451. 
Robb.  leg-holder,  568. 
Rotation  in  use  of  wards,  222. 
Routli,  fillet-carrier,  635. 
Rupture  of  blood-vessels,  546. 

of  heart,  546. 

of  organs,  525. 


Rupture  of  psoas  muscle,  546. 
of  spleen,  540. 
of  umbilical  vessels  in  velamentous 

insertion.  509. 
of  uterus,  525. 

Sacrum,  131. 

oscillatory  movements  of,  136. 
Salpingitis,  703,  709,  737. 
Salt,  normal  solution,  581. 
Saprsemia,  728. 
Sarcoma,  decidual,  752. 

of  uterus,  293. 
Scarlet  fever,  339,  798. 
Schlussplatte,  35. 
Schroeder,  vaginal   retractor    568. 
Schultze's  swingings,  560. 
Secretion,  45. 
Secundines,  198. 
Segment,  lower  uterine,  153. 
Segmentation,  24. 

nucleus  of,  24. 
Seibert,  milk  sterilizer,  249. 
Septicaemia,  340,  692. 

acutest,  706,  718,  746. 

in  children,  694. 
Serre-fine,  542. 
Serum,    antistreptococcic,    Marmorek's, 

734. 
Sex,  cause  of,  73. 
Shoulders,  passage  of,  193. 
Sickness,  monthly.  13. 
Sick-ward,  222. 

Siegemundin,  double  manoeuvre,  635. 
Sign,  Braun-Fernwald's,  103. 

Hegar's,  103. 
Signs  of  puerperal  state,  243. 
Silvester,  method  of  reviving,  561. 
Simon,  sharp  curette,  509. 
Simpson,   A.   R.,   axis-traction   forceps, 
595,  602. 
basilyst,  683. 

J.  Y.,  chloroform,  203. 
forceps,  598. 
Sims,  sharp  curette,  569. 
Sinus,  lactiferous,  94. 

urogenital,  277. 
Skin  diseases,  718. 
Smallpox,  339,  799. 

Smell ie.    method    of    delivering    after- 
coming  head,  384. 
Somatopleure,  37. 
Souffle,  uterine,   104. 


842 


INDEX. 


Soxhlet,  milk  sterilizer,  250. 
Space,  intervillous,  33. 
Speculum,  Brewer's,  117. 

Garrigues's  weight,   568. 

Sims's,  118. 
Spermatozoid,  21. 
Splanchnopleure,  37. 
Spleen,  717. 
Spondylolisthesis,  489. 
Spongiopiline,  742. 
Spot,  germinal,  13. 
Sprue,  806. 
Stalk,  abdominal,  42. 
Stethoscope,   187. 
Stomatitis,  gonorrhceal,  806. 
Streak,  primitive,  37. 
Stria;,  94,  95. 

albieantes,  95. 
Superfecundation,  257. 
Superfetation,  257. 
Supporter,  abdominal,  240. 
Sutures,  156. 
Symphyseotomy,  637,  655. 

Ayer's,  649. 

Harris's,  649. 

indications  for,  640. 

Morisani's,  648. 

Pinard's,  649. 

who  shall  perform?  656. 
Symphyseotomy-bandage,  653. 
Symphysis  pubis,   135. 
Syncytioma,  752. 
Syncytium,  31. 
Syphilis,  340. 
Syringes,  726. 

bulb  and  valve,  183. 

fountain,  182. 

urethral,  286. 
Systemic    disturbances    due    to    preg- 
nancy, 318. 

Table,  590. 

Daggett's,  108. 
Tamponade,  565. 
Tarnier,  axis-traction  forceps,  600. 

basiotribe,  683. 
Teeth,  caries  of,  321. 
Tetanoid  contractions,  791,  795. 
Tetanus,  324,  791. 

neonatorum,  817. 
Tetany,  323. 
Theca  externa,  10. 

interna,  10. 


Thomas,  craniotomy-foreeps,  682. 

dull  wire  curette,  569. 
perforator,  679. 
Thoracopagi,  410. 
Thorn-pelvis,  462. 
Thrombosis  of  artery,  781. 

of  pulmonary  artery,  784. 

of  uterine  sinuses,  36. 

of  venous  system,  782. 
Thrombus  of  vulva,  292. 
Thrush,  806. 

Thymus,  hypertrophy,  810. 
Toothache,  321. 
Transfusion,  582. 
Transmission      between      mother      and 

foetus,  44. 
Travail  insensible,  167. 
Triplets,  258. 
Tuberculosis,  342. 
Tumors,  malignant,  of  pregnancy,  752. 

of  a  vulva,  433. 

of  genitals,  289. 

ovarian,  432. 

springing   from    the    pelvic    bones, 
493. 

vaginal,  433. 
Tunica  intermedia,  66. 

media,  43. 
Turning,  618. 
Turns,  13. 

Tympania  uteri,  458,  707. 
Typhoid  fever,  339,  800. 
Twin  labor,  403. 
Twins,  258. 

locked.  407. 

Siamese,  409. 

Ulcer,  umbilical,  801. 
Umbilicus,  arteritis,  802. 

fungus,  801. 

gangrene,  802. 

hemorrhage,  801. 

phlebitis,  802. 

ulcer,  801. 
Unguentum  Crede,  732. 
Ureter,    course    of,    during    pregnancy, 

90. 
Urine,  examination  of,  128. 

incontinence,  777. 

retention,  334,  776. 
Uropoietie  organs,  diseases,  776. 
Utero-ovarian  amputation,  670. 
Uterus,  anteflexion,  755. 


INDEX. 


843 


Uterus    at    tlie    end    of    each    calendar 
month  of  pregnancy,  85. 
of  pregnancy,  86,  98. 
bicornis,  281. 
biloeularis,   282. 

blood-vessels   at  the   end  of    preg- 
nancy, 92. 
carcinoma,  432. 
compression,  194. 
contraction,  102. 
didelphys,  278. 
diseases,  747. 
duplex  separatus,  278. 
elevation,  758. 

entrance  of  air  into  vein,  786. 
faulty  contractions,  357. 
hernia,  301. 
horns,  276. 

hour-glass  contraction,  418. 
inertia,  357. 
innervation,   163. 
inversion,  516. 
involution,  228. 
lateroversion,  421    757. 
lower  segment,  153. 
lymphatics,  704. 
muscular  layer,  88. 
myoma,  429. 
nerves  of  pregnant,  93. 
partial  prolapse,  423. 
pressure  necrosis,  532. 
prolapse,  757. 
putrescence,  732. 
retroflexion,  756. 
retroversion,  756. 
rupture,  525. 
sacculation,  421. 
septus,  282. 
subinvolution,  747. 
superinvolution,  750. 
tetanus,  360. 
tympania,  707. 
unicornis,  279. 
vaginal  fixation,  420. 
ventral  fixation,  420. 
virgin,  84. 

Vagina,  155. 

atresia,  427. 
bacteriology,  125. 
change  of  color,  103. 
'  double,  428. 
gangrene,  730. 


Vagina,  haematoma,  521. 

laceration,  535. 

narrowness,  428. 

obstruction,  427. 

pressure  necrosis,  532. 

prolapse,  757. 

stenosis,  427. 

thrombus,  521. 
Vaginism,  428. 
Vaginitis,  284,  702. 
Vaporization,  267. 
Vectis,  617. 
Vegetations,  289. 
Veins,  varicose,  291. 
Ventilation,  220. 
Version,  618. 

Buseh's,  625. 

cephalic,  624. 

choice  of  hand,  62Q. 

compared    with    forceps    delivery, 
636. 

dangers  for  foetus,  636. 
for  mother,  636. 

D'Outrepont's,  625. 

external,  618. 

indication   for,    in   contracted   pel- 
vis, 466. 

internal  digital.  619. 
manual,  623. 

pelvic,  626. 

podalic,  627. 

spontaneous,  393. 
Vesicles,  718. 

blastodermic,  26,  36. 
.   germinal,  13. 

umbilical,  41,  72. 
Viability,  63. 
Villi,  fixation,  31. 

nutrition,  31. 
Vitellus,  13. 

Vomiting,  uncontrollable,  318. 
Vulva,  155. 

gangrene,  429,  730. 

hematoma,  521. 

laceration,  536. 

narrowness,  428. 

oedema,  429. 

thrombus,  521. 
Vulvitis,  702. 

Walcher,  hanging  posture,  591. 
Warts,  venereal.  289. 
Water-closets,  221. 


844 


INDEX. 


Waters,  bag  of,  170. 

external,  170. 

first,  168. 
Weakness,  congenital,  253. 
Weaning,  239. 


Wet-nurse,  248,  760. 
Yolk-sack,  37,  41. 
Yolk-stalk,  42. 

Zona  pellueida,  13. 


THE    END. 


